The utility of neuroimaging in the evaluation of children with migraine orchronic daily headache who have normal neurological examinations

Objectives.-To assess the utility of neuroimaging in the evaluation of chil dren presenting with two of the most common forms of headache, migraine and chronic daily headache, and to determine the utility and pathological yiel d of neuroimaging in specific headache syndromes in children whose neurolog ical examinations are normal. Methods.-We retrospectively reviewed the medical records of patients coded for headache (ICD 784) in the Pediatric Neurology Clinic at Children's Hosp ital of the King's Daughters between 1997 and 1999. The age range considere d tvas between 6 and 18 years. The study focused on the two most common typ es of headache, uncomplicated migraine and chronic daily headache. Only pat ients with normal physical and neurological examinations were considered in this analysis. Results.-Three hundred two patients were coded for headache within the defi ned age group. One hundred seven (35.4%) patients fulfilled IHS-R criteria as having uncomplicated migraine with a normal examination, and 30 (9.9%) p atients fulfilled criteria for chronic daily headache. Twenty-nine (9.6%) p atients presented with migraine-like symptoms, and 6 (2.0%) presented with chronic daily symptoms, but had neurological abnormalities present on exami nation. The remainder of the patients with headache had the following etiol ogies: 50 (16.6%) with secondary headache, 22 (7.3%) with complicated migra ine, 20 (6.6%) with posttraumatic headache, 13 (4.3%) with seizure-related headache, 11 (3.6%) with brain tumors, 10 (3.3%) with tension-type headache , and 4 (1.3%) with pseudotumor cerebri. Of the 107 patients with migraine, 42 (39.3%) received CT scans; 2 (4.8%) o f which were considered "abnormal.'' One of the abnormalities was an arachn oid cyst and the other was a dilated Virchow-Robin space. Twelve (11.2%) pa tients with migraine received an MRI, 2 (16.7%) of which were considered ab normal. Both of the abnormal findings were Chiari type I malformations. Of the 30 patients with chronic daily headache, 17 (56.7%) received CT scan s, 3 (17.6%) of which were considered abnormal. The abnormalities consisted of a maxillary opacification, a mucous retention cyst, and an occult vascu lar malformation. Eight (26.7%) of the patients,vith chronic daily headache had an MRI, 2 (25.0%) of which were abnormal. One of the abnormalities was a Chiari I malformation, and the other was an occult vascular malformation . Conclusion.-The yield of neuroimaging in children with uncomplicated migrai ne and normal neurological examination was 3.7%. The yield in children with chronic daily headache and normal neurological examination was higher at 1 6.6%. The abnormalities discovered included arachnoid cysts, Chiari I malfo rmations, sinus disease, occult vascular malformations and "dilated Virchow -Robin spaces." While none of the neuroimaging findings were apparent clini cally, their discovery did not influence the diagnosis, management, or outc ome of the patients. None of the abnormalities necessitated surgical interv ention or were associated with the headache presentation. Therefore, neuroi maging is not warranted in children and adolescents with defined clinical h eadache syndrome diagnoses whose neurological examinations are normal.