Christopher B. Oakley, MD Reviewing Bear JJ et al., Neurology 2017 Aug 1; 89:469
A retrospective case analysis finds no association between occipital headache location and intracranial pathology.
The International Classification of Headache Disorders (ICHD-3 beta) suggests that headaches localizing to the occipital region in children may be indicative of an intracranial process. This sentiment, however, is not noted in the American Academy of Neurology (AAN) and Child Neurology Society (CNS) practice parameters. To determine if there is merit to the assumed association, researchers conducted a retrospective chart review study of patients presenting to a child neurology clinic in 2009.
Of nearly 600 patients screened, 308 were included in the study. Forty-two children reported pain in the occipital area, 21 exclusively. Overall, two thirds (205 of 308) received neuroimaging but almost 90% of those with occipital pain received imaging (37 of 42). Of all those imaged, only four had a concerning finding (2 tumors, 1 of which was considered incidental, and two with signs of increased intracranial pressure). None of the four reported occipital pain. The authors conclude that occipital pain in the absence of abnormal history or clinical findings is neither uncommon nor concerning for intracranial pathology yet leads to more imaging than other pediatric headaches.
The ongoing concern that occipital pain is indicative of an underlying intracranial process in pediatric headache patients prompted this study. The findings reaffirm the AAN and CNS pediatric headache practice parameters regarding neuroimaging — the key is the neurologic exam and history. Despite nearly all children with occipital headaches receiving neuroimaging, including computed tomography in many cases, occipital pain did not correlate with an underlying intracranial process, thus further making the case that the decision to image should not be based on pain location. In pediatric headache patients who have a nonconcerning history and normal exam, neuroimaging can generally be avoided, even in those with occipital pain.