It is important to note that meningeal enhancement can be seen on MRI following lumbar puncture and should not be confused with pathology. Imaging of the orbits including a coronal, fat-saturated T2-weighted sequence is recommended to better evaluate for dilatation of the optic sheaths [24]. In patients in whom there is high suspicion for Chiari I deformity, a noncontrast MRI scan of the brain to include a sagittal T2-weighted sequence of the craniocervical junction with optional phase-contrast CSF flow study at the craniocervical junction is the study of choice. The Chiari I deformity is a condition characterized by the herniation of the cerebellar tonsils through the foramen magnum with headache as its most common symptom in older children [35,36]. In children <3 years of age, abnormal oropharyngeal function is commonly demonstrated. In children >3 years of age, scoliosis (associated with syringohydromyelia) or headache worsened by the Valsalva maneuver are typical findings. Most literature agrees that occipital headache in children is rare and calls for diagnostic caution; however, isolated occipital and cervical pain are not characteristic symptoms of any headache group in the pediatric age group, and their presence or absence does not correspond to changes on conventional brain MRI [37]. Children with sickle cell anemia are a special subgroup of patients who require particular attention as recurrent headaches and migraines in these children are common and undertreated [17]. Low hemoglobin levels and high pain rates are associated with recurrent headaches and migraines, whereas silent cerebral infarction is not. However, acute headache in children with sickle cell anemia is more frequently associated with acute central nervous system events than in the general pediatric population, so the threshold to image these patients should be lower.
Headache Child PCAs. It is important to note that meningeal enhancement can be seen on MRI following lumbar puncture and should not be confused with pathology. Imaging of the orbits including a coronal, fat-saturated T2-weighted sequence is recommended to better evaluate for dilatation of the optic sheaths [24]. In patients in whom there is high suspicion for Chiari I deformity, a noncontrast MRI scan of the brain to include a sagittal T2-weighted sequence of the craniocervical junction with optional phase-contrast CSF flow study at the craniocervical junction is the study of choice. The Chiari I deformity is a condition characterized by the herniation of the cerebellar tonsils through the foramen magnum with headache as its most common symptom in older children [35,36]. In children <3 years of age, abnormal oropharyngeal function is commonly demonstrated. In children >3 years of age, scoliosis (associated with syringohydromyelia) or headache worsened by the Valsalva maneuver are typical findings. Most literature agrees that occipital headache in children is rare and calls for diagnostic caution; however, isolated occipital and cervical pain are not characteristic symptoms of any headache group in the pediatric age group, and their presence or absence does not correspond to changes on conventional brain MRI [37]. Children with sickle cell anemia are a special subgroup of patients who require particular attention as recurrent headaches and migraines in these children are common and undertreated [17]. Low hemoglobin levels and high pain rates are associated with recurrent headaches and migraines, whereas silent cerebral infarction is not. However, acute headache in children with sickle cell anemia is more frequently associated with acute central nervous system events than in the general pediatric population, so the threshold to image these patients should be lower.