Which scenario most strongly prompts neuroimaging in a child with headache?

• A. Worst-ever headache with abrupt onset
• B. Headache after exercise that resolves with rest
• C. Headache with neck stiffness but normal exam
• D. Occasional mild headache during the day

Answer: (A)

When evaluating headaches in a child, imaging is most strongly prompted by red flags that suggest a dangerous intracranial problem. The most compelling red flag is a headache that is the worst ever and begins abruptly, reaching maximal intensity right away. This pattern raises urgent concern for conditions such as intracranial hemorrhage, mass effect, or other acute CNS pathology, and imaging is needed to quickly rule out structural problems. In practice, a quick noncontrast head CT is often the first test to perform in this acute setting.

Other scenarios are less alarming for immediate imaging. A headache that starts after exercise and resolves with rest is commonly a benign exertional or migraine-type headache. Neck stiffness with a normal exam could raise concern for meningitis, but without other signs (fever, altered mental status, or focal deficits), it’s less likely to require emergent imaging. Occasional mild headaches during the day fit typical patterns of primary headaches and generally do not prompt imaging unless additional red flags appear.

So, the scenario with the sudden, worst-ever headache is the strongest cue to obtain neuroimaging.