Clinical Decision Rule for Pediatric Intracranial Pathology
Clinical Decision Rule for Pediatric Intracranial Pathology
The purpose of this study is to develop a clinical decision rule for patients seen in the
 pediatric emergency department for possible intracranial pathology. This a prospective study
 evaluating patients presenting with headache and migraine. The study is observational and
 does not impact patient care.
Background/Question: A significant number of children who present to the Emergency Department
 (ED) with headache or migraine undergo head imaging with Computed Tomography (CT) or Magnetic
 Resonance Imaging (MRI). However, there is relatively low yield in imaging neurologically
 normal patients based on prior studies. The goal of this study is to describe the utilization
 of head CT or MRI among pediatric ED patients with headache and migraine. The investigators
 plan to evaluate clinical and examination characteristics of these patients, and use this
 information to develop a clinical decision rule to help providers predict the risk of finding
 an abnormality that affects patient treatment.

 Design: The investigators will perform a study of all children between 6 and 18 years of age
 who present to the ED with headache or migraine. At the time of the visit providers will be
 asked to complete a questionnaire regarding exam and history without making any changes to
 patient care. The investigators will also contact a sub-group of patients who do not undergo
 MRI or CT, 12-14 weeks after discharge to ask about subsequent headache care after leaving
 our facility.

 Methods: All children age 6-18 years who present to the ED with a chief complaint of headache
 or migraine will be eligible for the study. Patients will be excluded if they meet any of the
 following criteria: trauma within 48 hours, previous neurosurgery (shunt included), known
 tumor, history of cerebral hemorrhage/ischemia, Sickle Cell Disease, thrombophilia, bleeding
 disorder or non-English speaker. ED Research Assistants and ED staff physicians and nurse
 practitioners will screen potential candidates and ask providers to review the inclusion
 criteria. If the eligibility criteria are met, the provider will complete a standardized data
 collection form regarding exam and history findings. Patient care will not be impacted or
 altered. Research Assistants will also provide a Parent Information Sheet (either during the
 visit, or by mail following the ED visit) to the family of those patients who are enrolled
 informing them they may be contacted following discharge. Medical records will be reviewed
 for all eligible patients to obtain information on patient demographics, course of treatment
 and diagnosis. For those patients who do not have any head CT or MRI performed at their
 visit, the family will be contacted 12-14 weeks later to determine if they have had
 subsequent care for their headache. If the family is unable to be reached by phone, the
 patient chart will be reviewed for any other pertinent visits.

 Analysis: For each patient characteristic examined, the investigators will look for a
 statistically significant difference between those patients who have normal head imaging, and
 those with abnormal imaging. Using the characteristics that are significantly different, the
 investigators will develop a clinical decision rule to help providers assess the risk of
 significant findings in an individual patient. The investigators will also develop a decision
 tree to help aid providers when deciding which patients need head imaging. A sample of
 patients will have two independent assessments to allow us to look for evidence of
 inter-rater reliability in our questionnaires.
Inclusion Criteria:

 -  Age 6-18 years

 -  Chief complaint of headache or migraine

 Exclusion Criteria:

 -  Exclusion criteria

 -  Head trauma within 48 hours

 -  Previous neurosurgery (shunt included)

 -  Personal history of brain tumor

 -  History of stroke or vascular abnormality

 -  Sickle Cell Disease

 -  Fever (temperature over 38 degrees C)