Redflags for the non-traumatic headache and their limitations in children presenting to ED
You are asked to see Tom, a 9-year-old boy who has presented to ED with his mum. He has a 48 hour history of a severe headache. It is worse on leaning forward and he has vomited twice this morning. He has had a low grade temperature and this was preceded by a viral illness. Your junior has looked at the paediatric red-flags for headache. They think Tom should have a CT scan and have asked for your advice.
Headaches are a common presentation in both primary and secondary care. The most common headaches seen in children are benign and include tension headaches, headaches associated with a viral illness, sinusitis, migraines and headaches related to short-sightedness. Migraine is the most common headache disorder in children presenting to ED. During the COVID-19 pandemic, increased screen time and eye strain have become significant triggering factors. The challenge for clinicians is picking out those children with sinister pathologies, such as life-threatening infections and brain tumours, from benign conditions.
The initial assessment of a headache starts with a good in-depth history followed by a complete physical and neurological examination, noting any red flag signs and symptoms. Consider a HEEADSSS assessment as this can provide valuable information as to triggering factors leading to not only the headache but the reason for the presentation. Red flags for headaches are not equal, however. For example, a headache that wakes a child from sleep (which is reported quite commonly) does not have the same weight as a headache in a child who has papilloedema on fundoscopy. Red flags for headaches are non-specific and should be used to guide our management and not dictate it.
What are the common red flags for headaches in children?
**SNOOPY IS WET**
Neurological signs (ataxia, papilloedema, focal neurology)
Occur in a high risk population (sickle cell disease, malignancy, those with shunts)
Postural (worse leaning forward, bending)
Younger age 2-3 yrs
Squint (new onset)
Waking from sleep
Early morning vomiting
A study of 224 2-17-year-olds presenting to the ED with headaches found that almost 88% of them had at least one red flag sign/symptom, with one-third of these children reporting several. A headache that woke them from sleep was reported in 34.8% and one that occurred soon after waking was reported by 39.7%. Around one-third of these children ended up having neuroimaging in the ED though the prevalence of intracranial abnormalities was only around 1%. Red flag findings are not uncommon in children. Because of these nonspecific findings we often end up performing unnecessary scans. Don’t hang the entire weight of your assessment on these nonspecific red flags, but instead use them to guide your management and differential diagnosis.
Why do we care?
Numerous studies have shown that increased radiation exposure leads to an increased risk of malignancy. A study in the Lancet from 2012 estimated that the risk of leukaemia or brain cancer could be tripled after exposure to CT radiation. A more recent study, in 2019, concluded that CT-related exposure increases brain tumour risk – but found no association with leukaemia. Large, sweeping statements have been made in the BMJ such as – “young people who undergo CT scans are 24% more likely to develop cancer than those who do not”. So, with this in mind, we really do not want to be putting children though the CT scanner unless this is really necessary. Even then we stick to the ALARA principle – As Low As Radiologically Acceptable.
So how do we improve this?
In clear-cut cases such as those with focal neurology, the emphasis is on getting an urgent CT Brain in ED. But in those cases where there is some uncertainty with no abnormalities on examination, we may have time to consider onward referral or discussion with a specialist team or we might arrange an MRI brain as an urgent outpatient scan. We don’t have to ‘rush’ into performing CTs on these children just because we can. In some cases, it is okay to ‘do nothing’ and see how things go. We can advise a check-up with an optician and ensure good safety net advice – so that if things do change or get worse their parents know to come back.
Tom has 3 loose red flags – headache with postural symptoms, headache with early morning vomiting (be it one day), and headache with fever. The junior doctor is right to consider these non-specific red flags and is directed to consult Headsmart.co.uk. A detailed history and examination reveal that Tom has acute sinusitis. He is discharged with a nasal saline spray and clear safety net and advice to return if things change or worsen.
Take home messages
- Importance of taking a detailed history covering red flags & perform a full neurological examination in children presenting to ED with headaches.
- Consider performing a HEEADSSS assessment in children presenting to ED with headache.
- Importance of being aware of red flags in paediatric headache – but use these to help guide your management and not to overrule your clinical assessment. SNOOPY IS WET is a helpful mnemonic.
- Be prepared to sometimes ‘do nothing’ other than offer early review if necessary with good safety net advice. Advising parents to get their child’s eyes checked may be of benefit.
- Headsmart is a key resource for Healthcare professionals.
- Together let’s try and reduce the amount of radiation exposure we are giving to our children.
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How CH, Chan WS. Headaches in children. Singapore Med J. 2014;55(3):128-131. doi:10.11622/smedj.2014029
Meulepas JM, Ronckers CM, Smets AMJB, et al. Radiation Exposure From Pediatric CT Scans and Subsequent Cancer Risk in the Netherlands. J Natl Cancer Inst. 2019;111(3):256-263. doi:10.1093/inci/div104 The BMJ. Small cancer risk following CT scans in childhood and adolescence confirmed. Available from: https://www.bmj.com/press-releases/2013/05/21/small-cancer-risk-following-ct-scans-childhood-and-adolescence-confirmed. Date Accessed: 04/04/22
Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012;380(9840):499-505. doi:10.1016/S0140-6736(12)60815-0
Raucci U, Della Vecchia N, Ossella C, et al. Management of Childhood Headache in the Emergency Department. Review of the Literature. Front Neurol. 2019;10:886. Published 2019 Aug23. doi:10.3389/fneur.2019.00886
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Tsze DS, Ochs JB, Gonzalez AE, Dayan PS. Red flag findings in children with headaches: Prevalence and association with emergency department neuroimaging. Cephalalgia. 2019;39(2):185-196. doi:10.1177/03331-2418781814.