Headache in an Italian pediatric emergency department

Although headache is a common complaint in childhood, [1] it is an unusual presenting symptom in ED. In our study, which represents the largest analysis of this complaint in a pediatric ED, [10‐13] we found that headache accounts for 1% of all visits. Similar rates were reported in smaller pediatric series (0.7–1.3%) [10, 13] and in adult studies (1–4%) [2‐4]. Regarding the Italian experience, data from adult analysis show a prevalence ranging from 0.6% for primary headaches in ED [5] to 0.8–2.35% of all ED complaints [6‐9]; no Italian pediatric series exist. Compared to previously reported pediatric data, a similar high frequency in school-age children and a more homogenous male-to-female ratio was observed [11, 13].

Differential diagnosis of the patient presenting with headache is essential to rule out organic diseases and situation of immediate danger. Earlier studies have shown that the most common cause of headache in childhood is secondary headache, mainly in the setting of an upper respiratory infection [10‐13]. Compared with previous pediatric reports, an unexpected data obtained in our population was the higher prevalence of primary headache diagnosis versus secondary forms, being the proportion of patients classified with primary headache 56.7% in our study versus 10% in Kan’s [13] and 20% in Burton’s [10]. Similar proportion of primary headaches are usually reported in adults [9, 14] and suggest an increasing awareness of primary headache as clinical disorder in childhood. As regards secondary headaches, viral illness represented the most common diagnosis. The overall frequency of “pathological” diagnosis was low (4%) and only a minority of children had neurological conditions such as proven VP shunt malfunction, brain tumor or cerebrovascular diseases. In all these patients, a detailed history and a careful neurological examination proved to be effective, enabling an appropriate diagnosis on first visit to ED. Taking into consideration that our hospital is the referring regional center for all pediatric diseases, subsequent “pathological” diagnoses in other hospitals are improbable.

Despite the high frequency of primary headache diagnosis, most of these patients were discharged with a diagnosis of “primary headache not otherwise specified” and only 9.6% of them were classified as having a migraine. Data observed may be the consequence of the methodological approach, which was retrospective. However, according with previous published data [2, 5, 7], the main impression is that most of ED pediatricians stop the diagnosis process upon the differential diagnosis between primary and secondary headache. A low experience in headache classification according to International Classification of Headache Disorders (ICHD) 2004 criteria can be supposed [15]. This might explain also the higher admission rate observed in our population (17.6%) compared to previous studies [16]. According with adults series, admission was more common for migraine patients [7, 17].

With regard to diagnostic work-up, the number of specialist consulting visits requested by ED physicians was high (28.2% of all patients), similar to frequencies reported by other studies (10–40%) [8, 18]. Neuroimaging (head CT scan or MRI) was performed on 8% of children, which on first glance appeared high given that 96% of all patients were ultimately diagnosed with a benign disease. However, 25% of those who underwent neuroimaging were ultimately diagnosed with a “pathological” process. Despite suggestions that imaging could be overused, our rates are not excessive and are fairly lower than that reported in other studies performed in the ED setting (Table 3) [3, 10, 13]. Furthermore, 30% of radiological procedures with normal findings were performed because of non-specific abnormalities observed at EEG; moreover, all EEG performed in absence of seizures resulted normal or showed non-specific abnormalities. According to practice parameters published by the American Academy of Neurology and the Child Neurology Society [19], our data confirm that EEG is not recommended in the routine evaluation of headache, as it is unlikely to define an etiology and may lead to the discovery of incidental benign abnormalities, with subsequent unnecessary investigations and hospital admission. In general, diagnostic studies are seldom required in evaluating headache in children without clinical evidence of underlying structural lesions. Neuroimaging should therefore be limited to children presenting to the ED with headache associated with symptoms and neurological signs predictive for intracranial pathology and in those with underlying risk factors (such as VP shunt).

With regard to therapeutic approach, only a minority of patients (40.5%) was treated with any type of analgesic. The use of acetaminophen was prevalent, with more than 70% of patients treated this way; in a smaller proportion of our population other medications such as antiemetics and opioids were used. Interestingly, response to therapy was not clearly indicated in all ED records. Furthermore, all repeated visits occurring shortly after the first ED admission were due to headache unresponsive to previous ED therapy. It is unclear why pain relief is not a priority in pediatric ED, but it is possible that the severity of headaches in children presenting to ED is not as serious as that experienced by adults. The absence of clinical guidelines specifically designed for headache therapy in pediatric emergency may interfere also on this habit and on the choice of medications [13].

No previous pediatric study has investigated the usefulness of a specific follow-up program for these patients. Headache centers are dedicated to the treatment of primary headaches; they are uncommon in pediatrics and generally have a long waiting list. In our hospital there is a collaboration with the ED: according to ED doctors final decision, patients discharged with a diagnosis of primary headache or “headache not otherwise specified” are referred to our headache center and visited within 10–15 days. We feel this alliance is very important and suggest it might play a role in containing the “repeaters” phenomenon showed by Maizels [20]. This is a very expensive cluster of patients, accessing the ED more than three times in a period of 6 months. In the US experience these are 10% of the total population, accounting for about 50% of headache-related visits to the ED; using the same parameters, we found a low percentage of repeaters in our population (<1%). In particular, most of repeated visits (82.6%) occurred in patients who hadn’t been referred to headache center after first discharge from ED. Interestingly, only two patients regularly followed in headache center made a visit to the ED for headache complaints during the period studied. Neverthless, a prospective case-control study should be conducted to better define and assess the real impact of headache center on the “repeaters” phenomenon. Moreover, we suppose that collaboration between headache center specialists and ED staff might avoid unnecessary investigations in ED, as confirmed by the low rate of neuroimagings performed in our population compared with previous studies [3, 10, 13]. Last but not least, we consider the importance of providing a follow-up visit for a correct diagnostic definition according to ICHD-2004 criteria, as suggested by final diagnosis of migraine in children discharged from ED with a diagnosis of “primary headache not otherwise specified”. Nevertheless, we found that only 67.9% of primary headaches presenting to ED were referred to headache center; we observed also a low family adherence (53.8%) to headache center referral. It is possible that main concern of families attending ED is to receive reassurance that their children’s headache is not caused by a life-threatening disease; similarly, the main purpose of ED pediatricians seems to be the exclusion of secondary “pathological” headaches. An exact diagnostic definition and a follow-up program are probably less significant for families and ED staff too.

In conclusion, headache is a symptom accounting for 1% of all visits in our pediatric ED. The high frequency in the general pediatric population and vagueness of symptoms make headache a worrying symptom with the need to exclude a situation of immediate danger. At the same time, the majority of headaches are benign or secondary to self-limited viral illnesses; serious conditions, such as neurological disorders, are rare and could be diagnosed on the basis of a careful history and a detailed neurological examination. Use of diagnostic investigations, which represent a biological and economical burden for the whole population, should therefore be limited. Pain relief doesn’t seem a priority in pediatric ED; specifically designed guidelines are therefore needed in order to improve treatment of pediatric headache in the emergency setting. Collaboration with headache center staff, might limit repeated visits in ED, avoid unnecessary investigations, provide a correct diagnostic definition according to ICHD-2004 criteria and ensure an appropriate follow-up.