Headaches are common in children, and many tools, often related to neuroimaging, exist to diagnose the situation, but there remains little standardized procedure in approaching individual cases and little clarity around the benefits and risks of pursuing imaging.

Georgia researchers performed a review of 72 articles regarding pediatric headaches from 1995 to 2017. The team published findings online Jan. 9 in the American Journal of Roentgenology.

Here are four key findings:

1. Diagnostic criteria and evidence-based tools can determine if imaging is necessary

The American College of Radiology released appropriateness criteria in 2014 on imaging utilization for headaches in adults and children, with the 2017 version still pending. The group “supports the notion that, for children, imaging usually is not appropriate in the clinical setting of chronic or recurrent headaches, including migraine, without neurologic signs of increased intracranial pressure,” wrote Nadja Kadom, with the department of radiology and imaging sciences at Emory University School of Medicine in Atlanta.

The study also notes the ACR suggests “in the acute setting, particularly where there is concern for acute subarachnoid hemorrhage, CT may be the best imaging choice, whereas children with signs of increased intracranial pressure or positive neurologic signs, MRI may be preferred over CT.”

2. Parental concerns account for a large chunk of imaging requests

A recent study examined in this discussion investigated 449 patients with headaches who were referred to a neurology clinic. Some 72.2 percent underwent brain MRI, with 18.2 percent due to parental concerns. Furthermore, the discussion states that “the magnitude of imaging studies performed because of parental concern (81.8 percent) indicates how difficult it can be for physicians to argue against neuroimaging,” Kadom, et al. wrote in the discussion.

3. Ionizing radiation exposure should be considered

“Radiation exposure in children is cited as an argument to avoid CT, but exposure to ionizing radiation has to be considered in the context of the exposed body part (i.e., effective dose), one time versus cumulative radiation exposure risks, and comparative cancer risk of natural background exposure,” wrote Kadom and colleagues.

4. Cost of imaging is often not considered—but should be

A cost-effectiveness study compared three groups of children by risk for underlying brain tumor and cost of cross-sectional imaging. The first group consisted of low-risk children who had chronic non-migraine headaches for more than six months.

The second comprised children with intermediate risk who had migraine headaches and a normal neurologic exam. The third group was high-risk children with migraine headaches for less than six months and an abnormal neurologic exam.

Results of that study found the most effective strategy was an MRI in the high-risk group, yielding a cost-effectiveness ratio of $113,800 per quality-of-life years gained, compared with more than $1 million in the intermediate-risk group, and CT or MRI was the most cost-effective image modality among low-risk patients.