OBJECTIVE:To determine the implications of occipital headache in children and clarify when imaging is indicated.BACKGROUND:Occipital headache in children is considered a warning sign of intracranial pathology. The new ICHD-3 beta criteria for migraine state, "Occipital headache in children is rare and calls for diagnostic caution." Support for this comes from studies in emergency departments rather than neurologists' offices.DESIGN/METHODS:We performed a retrospective chart review cohort study of all patients referred to a child neurology clinic for headache in 2009. Patients were stratified by headache location: solely occipital, occipital plus other area(s) of head pain, or no occipital involvement. We assessed location as a predictor of 1) whether neuroimaging was ordered, and 2) whether intracranial pathology was found. Analyses were performed using logistic regression, Chi-Square, and Fisher's exact tests.RESULTS:A total of 356 patients were included. Median age was 12.1 years (27 months to 18 years), and 56.5% were female. Headaches were solely occipital in 6.4% and occipital-plus in 13.2%. Patients with occipital head pain were more likely to undergo neuroimaging than those without occipital involvement (solely occipital: 91%, RR 4.9, 95% CI 1.2-20.6; occipital-plus: 85%, RR 2.7, 95% CI 1.2-5.8; no occipital pain: 65%, ref.). Occipital pain alone or with other locations was not significantly associated with radiographic evidence of elevated intracranial pressure, tumor, benign cyst, or sinusitis. Occipital pain was associated with Chiari I malformation (solely occipital: RR 4, 95% CI 1.2-13.5; occipital-plus: RR 3.3, 95% CI 1.5-6.9).CONCLUSIONS:Children with occipital headache are more likely to undergo neuroimaging. In our study, occipital pain was associated with Chiari I malformation but not with more serious intracranial pathology. Detecting a Chiari I malformation is useful only if the clinical presentation is consistent with tonsillar compression; otherwise, it may be an incidental finding in a child with migraine. Without a worrying history and with a normal examination, neuroimaging can be deferred in most pediatric patients when occipital pain is present.
Disclosure: Dr. Bear has nothing to disclose. Dr. Gelfand has received personal compensation in an editorial capacity for Journal Watch Neurology. Dr. Goadsby has received personal compensation for activities with Allergan, Inc., Colucid, MAP Pharmaceuticals, Merck Sharp & Dohme Limited, eNeura, ATI, Boston Scientific Corporation, Eli Lilly & Company, Medtronic, Inc., Bristol-Myers Squibb Company, Amgen Inc., Arteaus, AlderBio, Pfizer Inc., Zogeniz, Nevrocorp, Ipmax, DrReddy, and Zosano. Dr. Goadsby has received research support from Amgen Inc., Merck Sharp & Dohme Limited, and Allergan, Inc. Dr. Bass has nothing to disclose.
Original Article: http://www.neurology.org/cgi/content/short/82/10_Supplement/P4.324?rss=1
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