PracticeUpdate: Neurology - Winter 2018

EDITOR’S PICKS 5

Emergency Department Neuroimaging for Red Flag Findings in ChildrenWith Headaches Cephalalgia: An International Journal of Headache Take-home message • “Red flags” have been used as a justification for emergent neuroimaging for children with headaches when they present to the emergency department. However, little data exist regarding the prevalence and outcomes of these findings, or the prevalence of emergent intracranial abnormalities in this population. The authors report that, among the 224 patients prospectively enrolled in this observational study, 197 (87.9%) had at least one red flag finding on history and a third of the children reported several red flags, including headache waking from sleep (34.8%) and headache present or soon after waking (39.7%) or headaches increasing in frequency, duration, and severity (40%, 33.1%, and 46.3%). While 33% percent of children received emergency department neuroimaging, the prevalence of emergent intracranial abnormalities was only 1%. • For the practitioner, this is an interesting observation, suggesting that the prevalence of red flags in children is associated with emergency department neuroimaging while the risk of emergent intracranial abnormalities is low. Nonspecific red flag findings may lead to unnecessary neuroimaging in these children. Omar Khan MD

Abstract BACKGROUND Clinicians appear to obtain emergent neuroimaging for children with headaches based on the presence of red flag findings. However, little data exists regarding the prevalence of these findings in emergency department populations, and whether the iden- tification of red flag findings is associated with potentially unnecessary emergency department neuroimaging. OBJECTIVES We aimed to determine the preva- lence of red flag findings and their association with neuroimaging in otherwise healthy children presenting with headaches to the emergency department. Our secondary aim was to deter- mine the prevalence of emergent intracranial abnormalities in this population. METHODS A prospective cohort study of oth- erwise healthy children 2-17 years of age presenting to an urban pediatric emergency department with non-traumatic headaches was undertaken. Emergency department physicians completed a standardized form to document headache descriptors and characteristics, associated symptoms, and physical and neu- rological exam findings. Children who did not receive emergency department neuroimag- ing received 4-month telephone follow-up. Outcomes included emergency department neuroimaging and the presence of emergent intracranial abnormalities. RESULTS We enrolled 224 patients; 197 (87.9%) had at least one red flag finding on history. Sev- eral red flag findings were reported by more than a third of children, including: Headache waking from sleep (34.8%); headache present with or soon after waking (39.7%); or headaches " Nonspecific red flag findings may lead to unnecessary neuroimaging in these children. "

flag findings is associated with emergency department neuroimaging, although the risk of emergent intracranial abnormalities is low. Many children with headaches may be receiv- ing unnecessary neuroimaging due to the high prevalence of non-specific red flag findings. Red Flag Findings in Children With Headaches: Prevalence and Association With Emergency Department Neuroimaging. Cephalalgia 2018 Jun 06;[EPub Ahead of Print], DS Tsze, JB Ochs, AE Gonzalez, PS Dayan. www.practiceupdate.com/c/70300

increasing in frequency, duration and severity (40%, 33.1%, and 46.3%). Thirty-three percent of children received emergency department neuroimaging. The prevalence of emergent intracranial abnormalities was 1% (95% CI 0.1, 3.6). Abnormal neurological exam, extreme pain intensity of presenting headache, vomiting, and positional symptoms were independently associated with emergency department neuroimaging. CONCLUSIONS Red flag findings are common in children presenting with headaches to the emergency department. The presence of red

VOL. 3 • NO. 3 • 2018