If there is strong concern for arterial dissection within the head and/or neck, the diagnosis is generally made by MRI or MRA [26]. Arteriography In children with sudden onset of severe headache and a positive MRI or CT study demonstrating intracranial hemorrhage or stroke, digital subtraction arteriography can be performed. Arteriography is an invasive procedure that requires a skilled angiographer to be available emergently. Discussion of Procedures by Variant Variant 1: Child. Primary headache. Initial imaging. Radiography There is no role for radiography in patients with primary headache. MRI In a study by Yilmaz et al [12] of 449 children with headache, approximately 55% of children had migraine, 30% had tension-type headaches, 10% had secondary headaches, and 5% were unspecified. Twenty-one percent of imaged children (n = 324) had abnormalities identified on their MRI examinations, largely incidental findings, with <1% having relevant findings to explain the headache, namely tumor with hydrocephalus. Similarly, Martens et al [11] found that despite findings on neurological/physical examinations in a substantial number of children with headaches, mostly migraines, the yield of brain MRI scans was low. Therefore, the yield of brain MRI is not contributory to the diagnostic and therapeutic approach. In unusual circumstances when a complete physical examination is not possible or a thorough history is not available MRI could be considered. CTA There is no role for CTA in patients with primary headache and no concerning findings on clinical or physical examination. CTV There is no role for CTV in patients with primary headache and no concerning findings on clinical or physical examination. MRA There is no role for MRA in patients with primary headache and no concerning findings on clinical or physical examination. MRV There is no role for MRV in patients with primary headache and no concerning findings on clinical or physical examination.
Headache Child PCAs. If there is strong concern for arterial dissection within the head and/or neck, the diagnosis is generally made by MRI or MRA [26]. Arteriography In children with sudden onset of severe headache and a positive MRI or CT study demonstrating intracranial hemorrhage or stroke, digital subtraction arteriography can be performed. Arteriography is an invasive procedure that requires a skilled angiographer to be available emergently. Discussion of Procedures by Variant Variant 1: Child. Primary headache. Initial imaging. Radiography There is no role for radiography in patients with primary headache. MRI In a study by Yilmaz et al [12] of 449 children with headache, approximately 55% of children had migraine, 30% had tension-type headaches, 10% had secondary headaches, and 5% were unspecified. Twenty-one percent of imaged children (n = 324) had abnormalities identified on their MRI examinations, largely incidental findings, with <1% having relevant findings to explain the headache, namely tumor with hydrocephalus. Similarly, Martens et al [11] found that despite findings on neurological/physical examinations in a substantial number of children with headaches, mostly migraines, the yield of brain MRI scans was low. Therefore, the yield of brain MRI is not contributory to the diagnostic and therapeutic approach. In unusual circumstances when a complete physical examination is not possible or a thorough history is not available MRI could be considered. CTA There is no role for CTA in patients with primary headache and no concerning findings on clinical or physical examination. CTV There is no role for CTV in patients with primary headache and no concerning findings on clinical or physical examination. MRA There is no role for MRA in patients with primary headache and no concerning findings on clinical or physical examination. MRV There is no role for MRV in patients with primary headache and no concerning findings on clinical or physical examination.