Occipital Headaches and Neuroimaging in Children

  • Samantha L. IrwinEmail author
  • Amy A. Gelfand
Childhood and Adolescent Headache (S Evers, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Childhood and Adolescent Headache


Purpose of Review

The goal of this review is to outline the prevalence and significance of occipital headaches in children and how they relate to neuroimaging findings. We seek to evaluate the concern that occipital headaches in children are indicative of secondary headache pathology by reviewing the yield of neuroimaging in pediatric patients with occipital headache location.

Recent Findings

Occipital headaches are a common presentation of primary headache disorders in children, seen in 7–16% of children presenting for evaluation of headache and in up to 20% of children diagnosed with migraine in the emergency department. Review of recent literature confirms that in and of itself, occipital location of headache in a child with recurrent headache and a normal physical examination should not be regarded as worrisome. Headaches with associated signs on neurologic examination should be investigated for a secondary cause, regardless of headache location. Occipital headaches that do not meet criteria for a primary headache disorder should be evaluated for site-specific occipital headache conditions. Neuroimaging for recurrent headache in children who have normal neurological examinations has an overall low yield (0–4.1%) for actionable findings in recent studies. Importantly, an abnormal neurologic examination often predicts the presence of neuroimaging abnormalities.


In the absence of an atypical history or abnormalities on clinical examination, occipital headaches in children are no more likely to be associated with intracranial pathology than headaches in other locations. If the child’s headaches are otherwise consistent with migraine or another primary headache disorder, and the neurologic examination is normal, the yield of neuroimaging is low, and imaging can generally be deferred.


Pediatric headache Occipital headache Site locked headache Neuroimaging findings Incidental findings Secondary headaches 


Compliance with Ethical Standards

Conflict of Interest

Dr. Samantha Irwin is the co-founder and CEO of a company named HeadSoothe Nutraceuticals Inc. which is working to develop a combination nutraceutical for the treatment of headache in children. This company is not associated with this work. Dr. Amy Gelfand has received honoraria from UpToDate and consulting fees from Zosano, Eli Lilly, and Biohaven. eNeura provides consulting payments for work done by Dr. Gelfand to the UCSF Pediatric Headache program. Her spouse receives consults for Genentech, research support from Genentech, Quest Diagnostics and MedDay, and personal compensation for medical-legal consulting.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major Importance

  1. 1.
    •• Headache Classification Committee of the International Headache Society The International Classification of Headache Disorders, 3rd edition. Cephalalgia [Internet]. 2018 Jul 1 38(1):1–211. New headache criteria. Google Scholar
  2. 2.
    Dodick DW. Clinical clues and clinical rules: primary vs secondary headache. Adv Stud Med. 2003;3(June):550–5.Google Scholar
  3. 3.
    Kabbouche MA, Cleves C. Evaluation and management of children and adolescents presenting with an acute setting. Semin Pediatr Neurol. 2010;17(2):105–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Irwin S. When to worry about a migraine and seek emergency medical attention. 2016.
  5. 5.
    Gofshteyn JS, Stephenson DJ. Diagnosis and management of childhood headache. Curr Probl Pediatr Adolesc Health Care. 2016;46(2):36–51.CrossRefPubMedGoogle Scholar
  6. 6.
    Bonthius DJ, Lee AGHA. Headache in Chidren: approach to evaluatin and general management strategies. Up To Date. 2017;Google Scholar
  7. 7.
    Lewis DW. Red flags in children who present with headache—how to recognize a serious problem: commentary. Nat Clin Pract Neurol. 2008;4:412–3.CrossRefPubMedGoogle Scholar
  8. 8.
    •• Genizi J, Khourieh-Matar A, Assaf N, Chistyakov I, Srugo I. Occipital headaches in children: are they a red flag? J Child Neurol. 2017;32(11):942–6. Recent evidence regarding occipital headaches CrossRefPubMedGoogle Scholar
  9. 9.
    •• Bear JJ, Gelfand AA, Goadsby PJ, Bass N. Occipital headaches and neuroimaging in children. Neurology. 2017;89(5):469–74. Recent evidence regarding occipital headaches. CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    • Eidlitz-Markus T, Zeharia A, Haimi-Cohen Y, Konen O. Occipital and craniocervical pain and brain MRI in children with migraine. Pediatr Neurol. 2014;50(4):347–52. Scholar
  11. 11.
    •• Ahmed MAS, Grossman S, Rafique B, Momoh Ojewuyi A. Site locked headaches in paediatric patients do not require routine brain imaging and rarely have a serious aetiology. Acta Paediatr Int J Paediatr. 2017;106(5):791–5. Recent evidence regarding occipital headaches. CrossRefGoogle Scholar
  12. 12.
    Ramirez-Lassepas M, Espinosa CE, Cicero JJ, Johnston KL, Cipolle RJBD. Predictors of intracranial pathologic findings in patients who seek emergency care because of headache. Arch Neurol. 1997;54(12):1506–9.CrossRefPubMedGoogle Scholar
  13. 13.
    Lewis DW, Qureshi F. Acute headache in children and adolescents presenting to the emergency department. Headache. 2000;40(3):200–3.CrossRefPubMedGoogle Scholar
  14. 14.
    Conicella E, Raucci U, Vanacore N, Vigevano F, Reale A, Pirozzi N, et al. The child with headache in a pediatric emergency department. Headache. 2008;48(7):1005–11.CrossRefPubMedGoogle Scholar
  15. 15.
    Raza-Knight S, Mankad K, Prabhakar P, Thompson D. Headache outcomes in children undergoing foramen magnum decompression for Chiari I malformation. Arch Dis Child. 2017;102(3):238–43.CrossRefPubMedGoogle Scholar
  16. 16.
    •• Lewis DW, Ashwal S, Dahl G, Dorbad D, et al. Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the quality standards subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2002;59(4):490–8. Pediatric guidelines for imaging. CrossRefPubMedGoogle Scholar
  17. 17.
    • Loder E, Weizenbaum E, Frishberg B, Silberstein S. Choosing wisely in headache medicine: the american headache society’s list of five things physicians and patients should question. Headache. 2013;53(10):1651–9. Headache guidelines. CrossRefPubMedGoogle Scholar
  18. 18.
    Strain JDACR. Appropriateness criteria on headache-child. J Am Coll Radiol. 2007;4(1):18–23.CrossRefPubMedGoogle Scholar
  19. 19.
    Frishberg BM, Rosenberg JH, Matchar DB, McCrory DC, Pietrzak MP, Rozen TD, et al. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. Am Acad Neurol [online] 2000;1–25.
  20. 20.
    Il RY, Chung HJ, Suh ES, Lee KH, Eun BL, Nam SO, et al. The role of neuroimaging in children and adolescents with recurrent headaches—multicenter study. Headache. 2011;51(3):403–8.CrossRefGoogle Scholar
  21. 21.
    Larson DB, Johnson LW, Schnell BM, Goske MJ, Salisbury SR, Forman HP. Rising use of CT in child visits to the emergency department in the United States, 1995-2008. Radiology. 2011;259(3):793–801.CrossRefPubMedGoogle Scholar
  22. 22.
    Gilbert JW, Johnson KM, Larkin GL, Moore CL. Atraumatic headache in US emergency departments: recent trends in CT/MRI utilisation and factors associated with severe intracranial pathology. Emerg Med J. 2012;29(7):576–81.CrossRefPubMedGoogle Scholar
  23. 23.
    Graf WD, Kayyali HR, Alexander JJ, Simon SD, Morriss MC. Neuroimaging-use trends in nonacute pediatric headache before and after clinical practice parameters. Pediatrics [Internet]. 2008;122(5):e1001–5.CrossRefGoogle Scholar
  24. 24.
    Jordan JE. Headache: for the expert panel on neurologic imaging. AJNR Am J Neuroradiol [Internet]. 2007;28(9):1824–6.Google Scholar
  25. 25.
    Wang H, Simonson T, Greco W, Yuh W. Brain MR imaging in the evaluation of chronic headache in patients without other neurologic symptoms. Acad Radiol. 2001;8(5):405–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Vernooij MW, Ikram MA, Tanghe HL, Vincent AJPE, Hofman A, et al. Incidental findings on brain MRI in the general population. N Engl J Med. 2007;357:1821–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Maytal J, Patel M, Eviatar L. The value of brain imaging in children with headaches. Pediatrics. 1995;96(3)Google Scholar
  28. 28.
    Dooley J, Camfield POM, et al. The value of CT scans for children with headaches. Can J Neurol Sci. 1990;17(3):309–10.CrossRefPubMedGoogle Scholar
  29. 29.
    Wöber-Bingöl C, Wöber C, Prayer D, Wagner-Ennsgraber C, Karwautz A, Vesely C, et al. Magnetic resonance imaging for recurrent headache in childhood and adolescence. Headache. 1996;36(2):83–90.CrossRefPubMedGoogle Scholar
  30. 30.
    Chu ML, Shinnar S. Headaches in children younger than 7 years of age. Arch Neurol. 1992;49(1):79–82.CrossRefPubMedGoogle Scholar
  31. 31.
    Lewis DW, Dorbad D. The utility of neuroimaging in the evaluation of children with migraine or chronic daily headache who have normal neurological examinations. Headache. 2000;40(8):629–32.CrossRefPubMedGoogle Scholar
  32. 32.
    Abu-Arafeh I, Macleod S. Serious neurological disorders in children with chronic headache. Arch Dis Child. 2005;90(9):937–40.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    •• Alexiou GA, Argyropoulou MI. Neuroimaging in childhood headache: a systematic review. Pediatr Radiol. 2013;43(7):777–84. Review of evidence for imaging in headache.CrossRefPubMedGoogle Scholar
  34. 34.
    Schwedt TJ, Guo Y, Rothner AD. “Benign” imaging abnormalities in children and adolescents with headache. Headache. 2006;46(3):387–98.CrossRefPubMedGoogle Scholar
  35. 35.
    Scagni P, Pagliero R. Headache in an Italian pediatric emergency department. J Headache Pain. 2008;9(2):83–7.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Goldstein J, Camargo C, Pelletier A, Edlow J. Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses. Cephalalgia. 2006;26(6):684–90.CrossRefPubMedGoogle Scholar
  37. 37.
    Ahmed MAS, Martinez A, Cahill D, Chong K, Whitehouse WP. When to image neurologically normal children with headaches: development of a decision rule. Acta Paediatr Int J Paediatr. 2010;99(6):940–3.CrossRefGoogle Scholar
  38. 38.
    Whitehouse A, Momoh-Ojewuyi A, Abusamara R, Al-Ani S, Alkilani R, Ahmed M. Occipital locked headache. J Headache Pain. 2013;14(S1):P181.CrossRefPubMedCentralGoogle Scholar
  39. 39.
    Hsiao HJ, Huang JL, Hsia SH, Lin JJ, Huang IA, Wu CT. Headache in the pediatric emergency service: a medical center experience. Pediatr Neonatol. 2014;55(3):208–12.CrossRefPubMedGoogle Scholar
  40. 40.
    Yilmaz Ü, Çeleǧen M, Yilmaz TS, Gürçinar M, Ünalp A. Childhood headaches and brain magnetic resonance imaging findings. Eur J Paediatr Neurol. 2014;18(2):163–70.CrossRefPubMedGoogle Scholar
  41. 41.
    Kan L, Nagelberg J, Maytal J. Headaches in a pediatric emergency department: etiology, imaging, and treatment. Headache. 2000;40(1):25–9.CrossRefPubMedGoogle Scholar
  42. 42.
    Tsushima Y, Endo K. MR imaging in the evaluation of chronic or recurrent headache. Radiology. 2005;235(2):575–9.CrossRefPubMedGoogle Scholar
  43. 43.
    Jordan JE, Ramirez GF, Bradley WG, Chen DY, Lightfoote JB, Song A. Economic and outcomes assessment of magnetic resonance imaging in the evaluation of headache. J Natl Med Assoc. 2000;92(12):573–8.PubMedPubMedCentralGoogle Scholar
  44. 44.
    The Childhood Brain Tumor Consortium. The epidemiology of headache among children with brain tumor. Headache in children with brain tumors. The childhood brain tumor consortium. J Neurooncol. 1991;10(1):31–46.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.The University of California, San Francisco (UCSF)Department of Neurology, Pediatric Brain Center, Child & Adolescent Headache ProgramSan FranciscoUSA

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