Neuroimaging in Migraine Critically Appraised Topic (CAT) PICOT Question: Does a head CT scan compared to no head CT scan change the management of a child with migraine? Clinical bottom line based on literature appraisal below: Neuroimaging (including computed tomography) in pediatric migraine headache has been demonstrated to NOT be effective (Graff, Kayyali, Alexander, Simon, & Morriss, 2008; Lateef, Grewal, McClintock, Chamberlain, Kaulas, & Nelson, 2009; Lewis, & Dorbad, 2000; Maytal, Bienkowski, Patel, Eviat, 1998; Romero, Picazo, Tapia, Romero, Diaz, & Romero, 1998). The American Academy of Neurology (AAN) makes the following tions on the neuroimaging of migraine headaches: 1. Obtaining a neuroimaging study on a routine basis is not indicated in recurrent headaches and a normal neurologic examination. 2. Neuroimaging should be considered in an abnormal neurologic examination (e.g. focal findings, signs of increased intracranial pressure, significant alteration of consciousness), the coexistence of seizures, or both. 3. Neuroimaging should be considered in children in whom there are historical features to suggest the recent onset of severe headache, change in the type of headache, or if there are features that suggest neurologic dysfunction (Lewis, Ashwal, Dahl, Dorbad, Hirtz, Prensky, & Jarjour, 2002). [GRADE = Strong tion / Moderate-quality evidence] Search strategy implemented: neuroimaging and children and headache).mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier] Search outcome: Eight papers were returned from the above search. One was a Systematic Review published in 2002; the second a retrospecti of CT scans in children 2-5 years old; the remaining articles are case studies. Synthesis of relevant studies: Author, date, country, and industry of funding Lewis, D.W., Ashwal, S., Dahl, G., Dorbad, D., Hirtz, D., Prensky, A. & Jarjour, I. (2002). Practice parameter: Evaluation of children and adolescents with Patient Group 6 studies, in which 605 of 1275 recurrent headache were ed. Mixed headache Various headache type, 62% were migraine CT Scans were performed on 116 children. An MRI was performed on 483 children. Level of Evidence (Oxford) / Strength of Evidence (GRADE) Level: 1 A Grade: Strong tion against using an intervention Research design Systematic Review Significant results Abnormalities were found in 97 children. 79 of the 97 abnormalities were considered to be incidental. 14 children had a surgically treatable lesion. No child with a normal neurologic examination had a surgically treatable lesion. Limitations Based on one prospective and 5 retrospective studies. Cannot determine homogeneity of the studies. No Clinical Decision Rule offered. 1
recurrent headaches. Neurology, 59, 490-498. Graff, W.D, Kayyali, H.R., Alexander, J.J., Simon, S.D. & Morriss, M.C. (2008). Pediatrics, 122(5), e1001- e1005. Lateef, T.M., Grewal, M., McClintock, W., Chamberlain, J., Kaulas, H. & Nelson, K.B. (2009) Pediatrics, 124, e12-e17 Both studies were obtained on 75 children Those not imaged were followed. 725 children and adolescents who were 3-18 years of age. Mean age of the patients was 10.2 years for boys and 111.4 years for girls. 364 children, 2-5 years of age. 5 ve, cross sectional chart 5 Physical and neurologic exams were normal as were medical, school and social histories. All weight, blood pressure and diet of all subjects were normal. Forty-five percent (325) had at least one neuroimaging study. The rate of neuroimaging ranged between 41-47% for the four selected years. No child had abnormal neuroimaging findings that lead to neurosurgery or major change in diagnosis. The majority of studies were ordered by primary care physicians (75.7%) and increased over the 13 years (Odds ratio: 1.4 [95% confidence interval: 1.10-1.78]; P= 0.006). Children with secondary HA were excluded.( 306 or 84% of subjects). Of the 58 remaining children 28% had CT scans performed. (16 children). One scan yielded abnormal resultsbrainstem glioma this subject demonstrated abnormal neurologic exam on the day of the presentation. For 15/16 children the DT scans did not contribute to diagnosis. Not aware of primary care physicians knowledge of neurology practice parameters which do not recommend neuroimaging in this instance. Change to electronic medical records means less data may have been available in early years, it may appear neuroimaging is increased, when in fact documentation is increased. 2
Romero, S.J., Picazo, A.B, Tapia, C.L., Romero, G.J., Diaz, C.R. & Romero, S.I. Effectiveness of brain imaging in headache. Anales de Pediatría, 49(5), 487-90 Alehan, FK. Value of Neuroimaging in the Evaluation of Neurologically Normal Children with Recurrent Headache. Journal of Child Neurology. 2002 Nov; 17(11):807-10. Patients (160) in Outpatient clinic for evaluation of headache over 3- year period. Ages 4-14. 95 consecutive children in outpatient clinic. 72 patients diagnosed with idiopathic headache (11.6 years +/- 3.2). 60 received neuroimaging (49 MRI, 11 CT). Grade: weak Case series 160 patients ed. Most diagnosed with either migraine (60%) or tension headache (29.5%). Sixty-six (41%) patients had CT imaging. 4/66 (6.1%) had structural changes on CT none deemed related to HA. Abnormalities on cranial MRI were millimeter foci of gliosis in four, sinusitis in two, pineal cyst in one, periventricular leukomalacia in one, arachnoid cyst in one, and gliotic changes owing to remote trauma in one. Cervical MRI performed in one patient, in addition to the cranial MRI because of associated neck pain, revealed a syrinx. Study design. Not set in ED (follow-up potential). Mixture of CT/MRI evaluation. Case series. No objective criteria to determine need/type of imaging CT scans were normal in nine patients and demonstrated the evidence of sinus disease in two. The overall percentage of abnormal findings detected on neuroimaging was 21.6. Only the presence of sinus disease, arachnoid cyst, and syrinx were thought to be possibly relevant to the pathogenesis of headache; thus, the percentage of findings causally related to the headache was about 10%. 3
Dooley, J.M., Camfield, P.R., O Neill, M., & Vohra, A. (1990). The value of CT scans for headache. Canadian Journal of Neurology Sciences, 17(3), 309-10. Maytal, J., Bienkowski, R.S., Patel, M., Eviat, R.l. (1998). The value of brain imaging in headaches. Pediatrics, 96,(3 Pt 1), 413-6. Lewis, D.W. & Dorbad, D. (2000). The utility of neuroimaging in the evaluation of migraine or chronic daily headache who have normal neurological examinations. Headache, 40(8), 629-32. 157 children at Pediatric neurology Clinic 133 children in Neurology Clinic 302 patients in Pediatric Neurology Clinic with normal neurologic exam and headache Grade: weak Case series 157 children evaluated. 7 CT head performed. 1/7 (14.2%) had abnormality. 133 patients; 78 patients with studies (27 CT, 45 MRI, 6 both). 11/78 with abnormalities: 7 sinusitis, 1 neuroepithelial cyst (no tx), 1 cerebral hemi-atrophy (no tx), 1 Dandy-Walker variant (no tx), 1 temporal arachnoid cyst. 95% probability that true rate of relevant abnormalities on neuroimaging in pediatric headache is 3.8% or less. 107 patients with migraine. 54 imaging studies (42 CT, 12 MRI). 4 (3.7%)abnormalities [Arachnoid cyst, dilated Virchow-Robin space, Chiari type I malformations (2)] 30 patients with chronic daily headache. 25 imaging studies (17 CT, 8 MRI). 5 (20%) abnormalities [maxillary sinusitis, mucous retention cyst, Chiari type I malformation, AVM (2)] Literature synthesis authored by: Nancy H Allen MS. RD, LD, CNSC Cole Condra, MD, MSc Clinical bottom line authored by: Migraine CPG Team Date created: Dec 2, 2009 4
References: Alehan, F.K. (2002). Value of neuroimaging in the evaluation of neurologically normal recurrent headache. Journal of Child Neurology, 17(11), 807-10. Dooley, J.M., Camfield, P.R., O Neill, M., & Vohra, A. (1990). The value of CT scans for headache. Canadian Journal of Neurology Sciences, 17(3), 309-10. Graff, W.D., Kayyali, H.R., Alexander, J.J., Simon, S.D. & Morriss, M.C. (2008). Neuroimaging-use trends in nonacute pediatric headache before and after clinical practice parameters. Pediatrics, 122(5), e1001-e1005. doi 10.4542/peds.2008-1159. Lateef, T.M., Grewal, M., McClintock, W., Chamberlain, J., Kaulas, H. & Nelson, K. (2009). Headache in young children in the emergency department: Use of computed tomography. Pediatrics, 124, e12-e17. doi 10.1542/peds.2008-3150. Lewis, D.W., Ashwal, S., Dahl, G., Dorbad, D., Hirtz, D., Prensky, A. & Jarjour, I. (2002). Practice parameter: Evaluation of children and adolescents with recurrent headaches. Neurology, 59, 490-498. Lewis, D.W. & Dorbad, D. (2000). The utility of neuroimaging in the evaluation of migraine or chronic daily headache who have normal neurological examinations. Headache, 40(8), 629-32. Maytal, J., Bienkowski, R.S., Patel, M., Eviat, R.l. (1998). The value of brain imaging in headaches. Pediatrics, 96,(3 Pt 1), 413-6. Romero, S.J., Picazo, A.B, Tapia, C.L., Romero, G.J., Diaz, C.R. & Romero, S.I. Effectiveness of brain imaging in headache. Anales de Pediatría, 49(5), 487-90. 5