Pediatric headache: Are the red flags misleading or prognostic?

Abstract

Background

Symptoms and findings called orange or red flags may indicate the etiology of pediatric headaches and may point to a life-threatening situation requiring urgent treatment and thus can alter patient management. These findings can be either misleading or prognostic for clinicians. We aimed to identify the etiology and prognostic value of orange/red flags in pediatric patients.

Methods

This study included 810 children with headaches who underwent neuroimaging due to the existence of orange/red flags. Their hospital records were examined to obtain demographical, clinical, laboratory data, and re-classify the headaches and determine orange/red flags on admission.

Results

Secondary causes were identified in 17.0% (n: 138) of patients, however, those who were diagnosed with a life-threatening headache that required emergency treatment were 5.2% of all patients and 30.4% of the patients diagnosed with a secondary headache. Those with secondary headaches and with life threatening secondary headaches which required urgent treatment were younger (p = 0,018, p = 0,022), had more emergency department visits (p < 0,001), and acute onsets (p < 0,001). Red flags, like systemic symptoms (p < 0,001), sudden onset (p = 0,023, p = 0.039), papilledema (p < 0,001), and progressive headaches (p = 0,048, p = 0.006), were more common with secondary headaches and its subgroup, while headache awakening from sleep (p = 0.009) and family history of primary headache (P > 0,001) were more common in primary headaches. No correlation existed between the number of red flags and etiology. However, older age (p = 0,001) and a shorter duration between symptoms and admission (p = 0,032), and the number of emergency service visits (p = 0,020) increased with increasing red flags.

Conclusions

Physicians always look for flags when they encounter patients with headaches, which is a common symptom, so as not to overlook anything. However, red flags do not always mean that the underlying cause requires emergency treatment and the severity of the cause is not correlated with the number of flags.

Introduction

Headaches are one of the most frequent causes of admission to pediatric neurology clinics and are rarely associated with a serious medical condition. Headaches are classified as primary or secondary depending on the underlying etiology [1]. Although secondary headaches are rare, some of them require urgent diagnosis and treatment. Thus, the existence of a secondary cause needs to be ruled out in children and adolescents using physical examination and laboratory techniques. Using a bundle that consists of blood tests and cranial imaging for every patient with a headache due to medicolegal concerns results in loss of time and resources [2]. Lewis et al, in their study concerning the approach to a patient with headache, evaluated red flags which should be taken into consideration prior to establishing a treatment plan [3]. However, in the current study, clinical observations revealed that while many primary headache patients had orange or red flags, patients with secondary headaches did not have these symptoms or if they did, the incidence was similar to that of patients with primary headaches.

The aim of this study is to evaluate orange and red flags present at the onset of headaches and their relation to headache subtypes, to identify their diagnostic value in children and adolescents who were admitted and subsequently underwent neuroimaging due to the existence of orange or red flags and classify the headaches, in a retrospective manner.