Neurosurgeons at Washington University School of Medicine, St Louis, MO, address the proposed utility and negative impact of guidelines proposed by the American Headache Society (AHS), in conjunction with the Choosing Wisely initiative of the American Board of Internal Medicine. The first of five recommendations approved by the AHS Choosing Wisely  Task Force, “Don't perform neuroimaging studies in patients with stable headaches that meet criteria for migraine,” is the subject of this neurosurgical perspective. The Choosing Wisely initiative focuses on reducing health care spending by setting guidelines to limit tests ordered by physicians, and if adopted, the guidelines threaten to negatively impact the care and outcomes of patients with brain tumors.
Patients with brain tumors may present with isolated headaches in the absence of other neurological symptoms and signs. Despite classic teaching, headaches caused by tumors may be similar to tension-type or migraine-type headaches in 77% and 9% of cases, respectively. A review of 95 patients (10 children) diagnosed with a brain neoplasm by open biopsy at Washington University found isolated headaches were the only complaint in 11.6% of brain tumor patients, and 24.2% presented with isolated headaches, no symptoms, or only non-specific symptoms. If the Choosing Wisely Task Force  recommendations had been followed, diagnosis would have been delayed or missed for 3 of 11 isolated headache patients (3.2% of all brain tumor patients). If the American College of Radiology/Consumer Reports recommendations had been followed, “Don't do imaging for uncomplicated headaches,” a diagnostic delay/error would have occurred for 7 of 11 isolated headache patients (7.4% of all patients). Under the proposed guidelines, neuroimaging would have been delayed or missed in 3%–7% of patients with brain tumors. Unvalidated guidelines to prevent neuroimaging in patients with headaches may reduce the perceived global economic burden at the expense of medical errors, delayed diagnoses and inferior outcomes for brain tumor patients. 
COMMENTARY. Headache in Children with Brain tumors.
Headache is the most common presenting symptom in children with brain tumors. In 139 children with brain tumor, a median of one symptom or sign was present at onset and six by diagnosis. Headache occurred in 55 (40%) children at onset and in 81 (58%) at diagnosis. Nausea and vomiting occurred in 39 (28%) at onset and 88 (63%) at diagnosis . In a review of 200 cases to determine the presenting features of brain tumors, the commonest first presenting symptom was headache in 41%, followed by vomiting in 12% . In a review of 55 children diagnosed with brain tumors, 19 (41%) of the tumors were supratentorial and 27 (59%) were infratentorial. Supratentorial tumors were associated with vomiting as the first symptom in 42%, seizures in 37% and headache in 31%. In children with infratentorial tumors, headache in 62% was the most common presenting symptom, followed by vomiting in 55% and ataxia in 48% of cases. The prediagnostic symptomatic interval had a median duration of 30 days with vomiting, 75 days with headache, and 75 days with ataxia. Diagnosis was often late in relation to the presenting symptom, especially headache .