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## Complete Summary

#### GUIDELINE TITLE

Headache - child.

#### BIBLIOGRAPHIC SOURCE(S)

Strain JD, Cohen HL, Fordham L, Gunderman R, McAlister WH, Slovis TL,
Smith WL, Rothner AD, Expert Panel on Pediatric Imaging.
Headache\--child. \[online publication\]. Reston (VA): American College
of Radiology (ACR); 2005. 6 p. \[36 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Strain JD, Strife JL, Kushner
DC, Babcock DS, Cohen HL, Gelfand MJ, Hernandez RJ, McAlister WH, Parker
BR, Royal SA, Slovis TL, Smith WL, Rothner AD. Headache. American
College of Radiology. ACR Appropriateness Criteria. Radiology 2000
Jun;215(Suppl):855-60.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Headache in children

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation

#### CLINICAL SPECIALTY

Family Practice\
Neurology\
Pediatrics\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations for
children with headache

#### TARGET POPULATION

Children with headache

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Computed tomography (CT), with and without contrast

2.  CT angiography (CTA)

3.  Magnetic resonance imaging (MRI), with and without contrast

4.  Magnetic resonance angiography (MRA)

5.  Invasive (INV), catheter angiography

6.  Nuclear medicine (NUC), single photon emission-computed tomography
    (SPECT)

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1 to 9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Headache - Child**

**Variant 1: Isolated headache (unaccompanied by neurologic signs and
symptoms or historical data).**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, head, without    2                    
  contrast                                 

  CT, head, with       2                    
  contrast                                 

  CTA, head            2                    

  MRI, head, without   2                    
  contrast                                 

  MRI, head, with      2                    
  contrast                                 

  MRA, head            2                    

  INV, catheter        2                    
  angiography                              

  NUC, SPECT, head     2                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 2: Headaches with positive neurologic signs or symptoms.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, head             8                   CT or MRI should be performed in
                                           every patient.

  MRI, head            8                   CT or MRI should be performed in
                                           every patient.

  INV, catheter        2                   Unless indicated by other studies.
  angiography                              

  NUC, SPECT, head     2                   Only helpful when further
                                           evaluating the lesion.

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 3: Headaches with supporting historical data (diplopia,
morning vomiting, headaches that awaken patient from sleep).**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, head            9                    

  CT, head             8                   MRI is recommended but CT is
                                           acceptable alternative.

  MRA, head            2                    

  INV, catheter        2                    
  angiography                              

  NUC, SPECT, head     2                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 4: Acute severe (thunderclap) headache and absence of family
history of migraine.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, head             9                   Non contrast preferred.

  MRI, head            8                   Either CT or MRI, not both.

  CTA, head            7                   Indicated if subarachnoid or
                                           parenchymal blood is identified on
                                           CT, MRI, or LP. Either CTA or MRA,
                                           not both.

  MRA, head            7                   Indicated if subarachnoid or
                                           parenchymal blood is identified on
                                           CT, MRI, or LP. Either CTA or MRA,
                                           not both.

  INV, catheter        6                   If MRA or CTA not available or if
  angiography                              intervention is considered.

  NUC, SPECT, head     2                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 5: Common or classic migraine (without neurologic findings).**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, head             2                    

  MRI, head            2                    

  MRA, head            2                    

  INV, catheter        2                    
  angiography                              

  NUC, SPECT, head     2                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

Headache is very common in children. The prevalence of headaches, in
patients age 7 years of age or younger, is 19 to 51%, with migraine
representing 1 to 5%. In large cross-sectional studies, 60% of children
7 to 15 years of age suffered from headaches, and 3 to 4% suffered from
migraines. In a U.S. study, the prevalence of headaches in studies of
adolescent boys and girls was 56% and 74%, respectively, with migraines
accounting for 3.8% and 6.6%, respectively.

Occasionally, headache heralds the development of a brain tumor or other
structural abnormality in a child; however, a large percentage of the
pediatric population suffers from headaches, whereas the annual
incidence of brain tumor in the pediatric age group approximates only 3
per 100,000 (0.003%). The need to distinguish headaches due to other
causes from headaches due to structural abnormalities is a major
dilemma. A review of the literature finds that most articles are
retrospective case series and have inherent bias. Reviews from pediatric
neurology or pediatric neurosurgical referrals bias the data when
evaluating structural anomalies associated with headache. Similar bias
comes from retrospective reviews provided through large brain tumor
consortiums. It is difficult to assess the health outcome of early
detection of any intracranial lesions, because the type, size, and
location determine their management. These issues are not unique to the
pediatric patient; they have also been discussed in a series of adult
literature reviews. Clinical experience from primary care physicians,
pediatricians, and neurologists indicates that neuroimaging studies have
a limited role in children with headaches.

The high prevalence of headaches and the low yield of imaging in
pediatric patients presenting with headaches alone bring into question
the value of screening for patients with \"isolated\" headaches. There
are, however, clinical conditions that influence the yield of positive
examinations. Numerous studies, most of which are retrospective, help
identify those findings or clinical characteristics that, when
associated with headaches, appear to be useful predictors of positive
imaging evaluation and therefore influence the appropriateness of
imaging. An isolated headache unaccompanied by neurologic signs,
presence of a seizure, or supporting historical data needs no imaging.

**Headaches with Positive Neurologic Signs or Symptoms**

Major studies addressing the issues of brain tumors and indications for
imaging, including the data from 3,291 children described in the
Childhood Brain Tumor Consortium, 315 children in the Boston Children\'s
review, and 72 children in the data of Honig and Charney, suggest that
nearly all children with intracranial tumors had symptoms or neurologic
signs accompanying their headache. The Childhood Brain Tumor Consortium
and the Honig and Charney data show that 94% of children with brain
tumors have abnormal neurologic findings at diagnosis. Sixty percent had
papilledema. Other neurological findings included gait disturbance,
abnormal reflexes, cranial nerve findings, and altered sensation.
Another research team identified papilledema, nystagmus, and gait
disturbances as univariant predictors of brain tumor. Confusion and
other assorted abnormal neurological findings were multivariant
predictors of brain tumors. It would appear appropriate from this
retrospective data to consider intracranial imaging, CT (with and
without contrast), or MRI in any patient presenting with headache and
positive neurologic findings.

**Supporting Historical Data**

There also appear to be specific historical data or headache
characteristics that are associated with intracranial pathology.
Headaches that awaken the child from sleep or occur on arising appear to
have clinical significance. Intense, prolonged, and incapacitating
headaches with an absent family history for migraine may indicate an
underlying pathology. Patients with headaches increasing in frequency,
duration, and intensity might benefit from imaging. Vomiting accompanied
headaches in 78% of patients in the study by Honig and Charney, and it
was also predictive of pathological process in the study by other
researchers. Individuals who have these specific historical data of
headache characteristics may benefit from CT with and without contrast.

**Sudden Severe Headache (thunderclap headache)**

Sudden severe headaches are more common in adults than in children.
These \"thunderclap headaches\" are predictive of subarachnoid
hemorrhage and place patients at risk for aneurysm or arteriovenous
malformation. Childhood intracranial aneurysms are rare, but many such
case reports document severe acute headache as the presenting symptom.
Sudden severe unilateral headaches in the pediatric population and in
young adults correlate with carotid or vertebral dissection, especially
when associated with neurologic signs and symptoms. In sudden severe
headaches, particularly in the absence of a family history of migraine,
a CT scan with and without contrast is recommended. If subarachnoid or
parenchymal hemorrhage is detected, CTA should be performed. Catheter
angiography may provide more definitive information but, more
importantly, may be considered for neurovascular intervention.

**Common or Classic Migraines**

By 15 years of age, children experience migraine headaches with a
frequency that varies from 3 to 5%, according to published studies.
There is a female predominance in migraines. The 1988 International
Headache Society described two types of migraine: migraine with aura
(classic), and migraine without aura (common). In classic migraine,
headache is preceded by an aura (17%). Common migraine is defined as
characteristically paroxysmal and separated by symptom-free intervals.
The most common symptoms are nausea, vomiting, abdominal pain, and
disturbance of vision. Visual symptoms include scintillating scotomata,
blurriness, transient hemianopia, or complete blindness in one eye
(amaurosis fugax). A family history of the disorder can be elicited in
more than half of the patients. Other symptoms include numbness and
tingling in one arm over the entire side, hemiplegia, aphasia, or
apraxia.

Clinicians have difficulty distinguishing the first, second, or third
migraine headache from headache caused by brain tumor, subarachnoid
hemorrhage, vasculopathy, arteriovenous malformation, or other
underlying disease processes. These patients may be imaged before the
diagnosis of migraine is established. One of the clues in
differentiating these headaches may relate to transient neurologic
findings versus persistent findings in tumor headaches. In 72 patients
with brain tumor headaches as described by Honig and Charney, abnormal
physical signs were present in 94% of the patients. Although migraine
may have many manifestations, it is usually not difficult to diagnose.
If the child has typical migraine with or without aura, most clinicians
would recommend no imaging studies. Children with migraine are symptom
free between headaches. No imaging is recommended in cases of common
migraine of more than 6 months\' duration in patients with a family
history of migraine and nonprogressive migraine attacks.

**Complicated Migraine (Those with Neurologic Deficit)**

Because the presenting signs and symptoms of complicated migraines with
focal neurologic findings cannot be discriminated from similar
presentations related to intracranial neoplasms, imaging is recommended.
Ophthalmologic migraine with focal neurologic symptoms of unilateral
ptosis or complete third nerve palsy is recommended to distinguish it
from other intracranial abnormalities.

In patients with miscellaneous migraine findings or syndromes such as in
vertigo, basilar artery migraine syndrome, persistent confusion migraine
syndrome, progressive chronic headache, or hemiplegic migraine, imaging
may be appropriate to exclude an aneurysm, a space-occupying lesion, or
other intracranial abnormality. Basilar artery migraine syndrome
includes vertigo, tinnitus, ataxia, dysarthria, and diplopia that
precede the onset of headache. These findings are believed to result
from brainstem ischemia; however, they must be differentiated from
stroke or other causes of ischemic lesions. MRI with diffusion is
recommended in these patients. Occasionally, arteriography or MRA may be
warranted.

**Sinogenic Headache**

Sinus disease may present with headache or may be associated with it.
The diagnosis of acute sinusitis in children is made clinically;
however, in children who present with severe and persistent headache as
the dominant feature of sinusitis, imaging may be warranted. Clinical
signs suggesting intracranial abnormality include high fever, confusion,
and change in mental status with and without focal signs. Headache is
the most common symptom identified with the intracranial spread of
infection resulting from dural irritation and localized encephalitis.
Occasionally, patients who present with various primary headache
syndromes without significant nasal or sinus symptoms and fail to
respond to conventional therapy are found to have evidence of sinusitis
on CT.

Epidural empyemas are collections of suppurative fluid located between
the skull and dura. They are less prevalent in young children than
adolescents. The most common underlying abnormality is paranasal
sinusitis. The differential diagnosis includes meningitis, subdurals,
brain abscess, and subarachnoid bleeding. Imaging is decisive and aids
treatment. The diagnostic choice is either CT or MRI. Contrast
enhancement can increase the conspicuousness of a subtle collection. MRI
may be preferable for diagnosing epidural empyemas because of its
ability to distinguish between different types of fluid. For patients
who present with transient headaches and sinus disease, no imaging is
warranted. For patients in whom headache is the dominant presenting
problem or for those with headache associated with mental status change
or neurologic findings, imaging is appropriate.

**Trauma**

Headache is rarely a presenting feature of acute trauma. Craniocervical
trauma accounts for 50% of deaths of children between 1 and 14 years of
age. Eighty percent of children who die from multisystem trauma have
associated head injuries. Trauma to the central nervous system is the
greatest cause of morbidity and mortality in children. In addition,
nonaccidental trauma is the leading cause of morbidity and mortality in
the abused child. Typically, the abused child presents without external
signs of trauma to the head, face, and/or neck, and the intracranial
injury is related to whiplash - shaken infant syndrome. Clearly,
intracranial imaging plays a critical role in the evaluation of the
acutely injured patient; however, because headache is rarely a major
indication for imaging, in the context of the clinical condition
headache, only the evaluation of headache related to subacute or remote
trauma will be considered.

Patients who have a history of subacute or remote trauma may present
with headaches. Currently, there is no published series evaluating
headaches that correlate neurologic signs and symptoms with imaging
findings. However, in adults, the complaint of headache has been
associated with an increased risk of intracranial injury, even in
patients suffering minor head trauma with Glasgow\'s coma scores greater
than 13. Thus, in children who have previous minor head trauma and who
are awake and alert with no neurological deficit, the indications for CT
or MR are not clear. Certainly, it would be prudent to consider imaging
of patients in whom neurologic signs or symptoms are positive, whose
headaches are associated with vomiting, or whose headaches are
increasing in frequency, duration, or severity, regardless of the
severity of the initial trauma.

**Headache with Fever or Known Underlying Disease**

Headache may accompany a febrile illness. Additional testing may be
required when meningitis or encephalitis is suspected. Neurologic signs
and symptoms such as nuchal rigidity or alteration in consciousness may
be indications for imaging. In addition, there are known underlying
disease processes that predispose patients to intracranial pathology.
Children with underlying disease \-- such as immunocompromised patients,
children with known neoplasms, sickle cell patients, and patients with
coagulopathy or hypertension \-- are predisposed to intracranial
pathology. In high-risk groups, the presence of a severe headache may
indicate significant intracranial pathology. It would seem appropriate
to consider a lower threshold for imaging in this patient population.

**Abbreviations**

-   CT, computed tomography

-   CTA, CT angiography

-   INV, invasive

-   LP, lumbar puncture

-   MRA, magnetic resonance angiography

-   MRI, magnetic resonance imaging

-   NUC, nuclear medicine

-   SPECT, single photon emission computed tomography

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for evaluation of
children with headache

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Strain JD, Cohen HL, Fordham L, Gunderman R, McAlister WH, Slovis TL,
Smith WL, Rothner AD, Expert Panel on Pediatric Imaging.
Headache\--child. \[online publication\]. Reston (VA): American College
of Radiology (ACR); 2005. 6 p. \[36 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1999 (revised 2005)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Pediatric Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: John D. Strain, MD; Harris L. Cohen, MD; Lynn Fordham,
MD; Richard Gunderman, MD, PhD; William H. McAlister, MD; Thomas L.
Slovis, MD; Wilbur L. Smith, MD; A. David Rothner, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Strain JD, Strife JL, Kushner
DC, Babcock DS, Cohen HL, Gelfand MJ, Hernandez RJ, McAlister WH, Parker
BR, Royal SA, Slovis TL, Smith WL, Rothner AD. Headache. American
College of Radiology. ACR Appropriateness Criteria. Radiology 2000
Jun;215(Suppl):855-60.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonPediatricImaging/HeadacheChildDoc3.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on March 30, 2006.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008