Researchers at multiple centers in Korea have retrospectively reviewed the records of all 1562 (male 724, female 838) new patients presenting with recurrent headaches in 9 Pediatric Neurology Clinics of tertiary hospitals. Headaches were classified according to the International Classification, 2nd ed. Neuroimaging was performed in 77.1% of patients, and overall, 9.3% (112/1204) were abnormal; 2.3% (5/214) in CTs, 8.6% (88/1022) in MRI, and 17.6% (19/108) in MRI and MR angiograms. The mean age of onset of headache was 8 years, the mean frequency of attacks was 13/month, and the mean duration of symptoms at presentation was 16 months. The highest yield was obtained in patients with an abnormal neurological examination, and 50% (9/18) were abnormal (P<.001). Lowest yields occurred when imaging was performed for changes in type of headache (12% [26/201]), neurologic dysfunction (10% [9/83]). recent onset of severe headaches (7% [12/171]), and demands of parent and physician (10% [21/208]). Surgery was performed in 0.9% patients who underwent neuroimaging, and in 9.8% with abnormal findings. Neuroimaging showed no significant relation with age, sex, headache type, age of onset, duration of symptoms, frequency, location, or intensity of headache (P>.05). The findings suggest that stricter guidelines are needed for neuroimaging in pediatric headache patients. 
COMMENT. Increased parental and physician demand, and fear of liability are some reasons listed for the excess use of neuroimaging in pediatric headache. Practice parameters include an abnormal neurological examination or history of neurologic dysfunction . Routine imaging is not indicated in patients with a normal neurologic examination . Clinical predictors of space-occupying lesions include headaches of <1 month duration, absent family history of migraine, abnormal neurologic examination, gait abnormalities, and occurrence of seizures . MRI indications proposed by Maytal J et al  include atypical recurrent headaches, recent change in the character of the headache, persistent vomiting, abnormal neurologic findings, and occurrence in younger age groups. Straussberg R et al  report 5 patients, ages 10 months to 4 years, with headache as the initial symptom of intracranial tumor, three having a normal neurologic exam. An abnormal neurologic examination is the strongest predictive factor for a brain tumor as a cause of headache but is not an essential criterion for MRI. Change in the type of headache is not a reliable factor.