In this study, there were no abnormal MRI reports in migraine, and only one abnormal MRI report was in tension-type headache. Similarly in the literature, Tsushima et al. reported that repeated neuroimaging was unremarkable in adults with chronic headache and had no features in previous neuroimaging, and neuroimaging was unnecessary in patients with normal neurological examination [
6]. On the other hand, it has been reported in publications that when no pathology is detected in neuroimaging, this will reduce the anxiety of the family and they can better cope with the headache [
7]. In our study, MRI was performed in 96.7% of migraine patients and 99.5% of tension-type headache, although the neurological examination was normal, moreover, almost one-fifth of these MRI’s were performed in the emergency room. This raises the question of when MRI should be performed in children with primary headache. This is a difficult and complex question to answer. Red flags, neurological examination, the child’s assessment and expression of the current headache, the approach of the physician evaluating the child, and as a result of all these, it becomes difficult to decide whether neuroimaging is needed. In our study, when MRI findings were evaluated, a tumor was found as an abnormal MRI finding in a patient with tension-type headache in the presence of papilledema, which is a neurological examination finding. Arachnoid cysts were found incidental as the most common MRI finding in this study(Fig.
1). The increasing use of MRI has led to more frequent diagnosis of arachnoid cysts. The percentage of patients with arachnoid cyst is found 5%. Al-Holou et al. reported that arachnoid cysts remained clinical and imaging stable with increasing age and did not require any intervention in their study in a large series of pediatric populations [
8]. On the other hand, surgery has been found to be beneficial when arachnoid cysts are symptomatic [
9], and it has been reported that surgically treated arachnoid cysts have headache with signs of increased intracranial pressure [
10]. In our study, arachnoid cysts were accepted as incidental because they did not show any signs of increased intracranial pressure in their current state. In this study, fundus examination, which is an important complementary part of the neurological examination, was the most important clue for secondary headache. The only abnormal MRI finding was found in a patient with papilledema. It is a known fact that one of the causes of papilledema is space-occupying lesions in the brain such as intracranial tumors [
11‐
13].
In our study, almost 20% of MRIs were taken in the emergency room. This situation forces us to consider for what indication the high-cost MRI was taken in the emergency room. Moreover, no reason for MRI was found for patients in group 3 who had no abnormal neurological examination findings or red flags. We can only assume that there may be physician or patient or family concerns, but due to the retrospective nature of our study, we cannot give an exact answer to this question. The relationship has been reported between childhood headache and the presence of emotional and behavioral symptoms. Children with headache may be more anxious and may describe the headache character differently than it actually is. This may affect the evaluation of families and physicians. Migraine, which is very common; it is known that psychiatric diagnoses such as depression, anxiety and post-traumatic stress disorder often accompany them [
14]. The sociocultural and economic levels of those describing migraine-type headache were found to be high. In addition, it has been found that most of these people have a high desire for success, perfectionist, prescriptive, meticulous and anxious. In many studies conducted after 1990, it has been determined that individuals with migraine go to centers specialized for headaches they have experienced due to these personality traits [
15]. Early onset of migraine in children and severity of migraine were associated with higher levels of family reunification [
16]. Considering the family history of migraine sufferers, the fact that both the children with migraine and their families are perfectionist, prescriptive, meticulous and anxious, may have led physicians to need neuroimaging as an additional examination, even if they do not have neurological symptoms. Since our study was designed retrospectively, the reasons for MRI of the patients in group 3 could not be explained. The limiting factor of this study is its retrospective design. It seems that we need to understand more about recurrent MRI requests in primary headaches. There is a need for future prospective studies to understand the attitude of physicians in emergency rooms or outpatient clinic We hope that future prospective studies will define the reasons that push the physician to request MRI in children who do not have abnormal neurological findings or red flags.
This study suggests that physician should spare time for fundus examination for children with primary headache during their regular office visits or in emergency rooms where they apply with headache.