{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T01:37:51Z","timestamp":1787017071919,"version":"build-2736575974"},"reference-count":42,"publisher":"BMJ","issue":"11","license":[{"start":{"date-parts":[[2023,11,22]],"date-time":"2023-11-22T00:00:00Z","timestamp":1700611200000},"content-version":"unspecified","delay-in-days":21,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000065","name":"National Institute of Neurological Disorders and Stroke","doi-asserted-by":"publisher","award":["R01NS110826"],"award-info":[{"award-number":["R01NS110826"]}],"id":[{"id":"10.13039\/100000065","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2023,10,16]]},"published-print":{"date-parts":[[2023,11]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Headache is a common chief complaint of children presenting to emergency departments (EDs). Approximately 0.5%\u20131%\u2009will have emergent intracranial abnormalities (EIAs) such as brain tumours or strokes. However, more than one-third undergo emergent neuroimaging in the ED, resulting in a large number of children unnecessarily exposed to radiation. The overuse of neuroimaging in children with headaches in the ED is driven by clinician concern for life-threatening EIAs and lack of clarity regarding which clinical characteristics accurately identify children with EIAs. The study objective is to derive and internally validate a stratification model that accurately identifies the risk of EIA in children with headaches based on clinically sensible and reliable variables.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and analysis<\/jats:title>\n                    <jats:p>Prospective cohort study of 28\u2009000 children with headaches presenting to any of 18 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). We include children aged 2\u201317 years with a chief complaint of headache. We exclude children with a clear non-intracranial alternative diagnosis, fever, neuroimaging within previous year, neurological or developmental condition such that patient history or physical examination may be unreliable, Glasgow Coma Scale score&lt;14, intoxication, known pregnancy, history of intracranial surgery, known structural abnormality of the brain, pre-existing condition predisposing to an intracranial abnormality or intracranial hypertension, head injury within 14 days or not speaking English or Spanish. Clinicians complete a standardised history and physical examination of all eligible patients. Primary outcome is the presence of an EIA as determined by neuroimaging or clinical follow-up. We will use binary recursive partitioning and multiple regression analyses to create and internally validate the risk stratification model.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethics and dissemination<\/jats:title>\n                    <jats:p>Ethics approval was obtained for all participating sites from the University of Utah single Institutional Review Board. A waiver of informed consent was granted for collection of ED data. Verbal consent is obtained for follow-up contact. Results will be disseminated through international conferences, peer-reviewed publications, and open-access materials.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2023-079040","type":"journal-article","created":{"date-parts":[[2023,11,22]],"date-time":"2023-11-22T12:36:41Z","timestamp":1700656601000},"page":"e079040","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":3,"title":["Stratification of risk for emergent intracranial abnormalities in children with headaches: a Pediatric Emergency Care Applied Research Network (PECARN) study protocol"],"prefix":"10.1136","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7567-8743","authenticated-orcid":false,"given":"Daniel S","family":"Tsze","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nathan","family":"Kuppermann","sequence":"additional","affiliation":[{"name":"Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, University of California Davis Health, Sacramento, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"T Charles","family":"Casper","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bradley J","family":"Barney","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6897-8668","authenticated-orcid":false,"given":"Lawrence P","family":"Richer","sequence":"additional","affiliation":[{"name":"Women and Children's Health Research Institute, Edmonton, Alberta, Canada"},{"name":"Department of Pediatrics, Division of Neurology, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Danica B","family":"Liberman","sequence":"additional","affiliation":[{"name":"Departments of Pediatrics and Population and Public Health Sciences, Division of Emergency and Transport Medicine, University of Southern California Keck School of Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pamela J","family":"Okada","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Division of Pediatric Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claudia R","family":"Morris","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sage R","family":"Myers","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Division of Pediatric Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jane K","family":"Soung","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rakesh D","family":"Mistry","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lynn","family":"Babcock","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Division of Emergency Medicine, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sandra P","family":"Spencer","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Division of Emergency Medicine, Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael D","family":"Johnson","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Division of Pediatric Emergency Medicine, The University of Utah School of Medicine, Salt Lake City, Utah, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eileen J","family":"Klein","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kimberly S","family":"Quayle","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Division of Pediatric Emergency Medicine, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5689-0255","authenticated-orcid":false,"given":"Dale W","family":"Steele","sequence":"additional","affiliation":[{"name":"Departments of Emergency Medicine, Pediatrics and Health Services, Policy & Practice, Warren Alpert Medical School and School of Public Health of Brown University, Providence, Rhode Island, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea T","family":"Cruz","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Divisions of Emergency Medicine & Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander J","family":"Rogers","sequence":"additional","affiliation":[{"name":"Departments of Emergency Medicine and Pediatrics, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Danny G","family":"Thomas","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jacqueline M","family":"Grupp-Phelan","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, UCSF Benioff Children's Hospital, San Francisco, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tiffani J","family":"Johnson","sequence":"additional","affiliation":[{"name":"Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, University of California Davis Health, Sacramento, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter S","family":"Dayan","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2023,11,22]]},"reference":[{"key":"2025121219443429000_13.11.e079040.1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpeds.2013.07.006"},{"key":"2025121219443429000_13.11.e079040.2","doi-asserted-by":"publisher","DOI":"10.1097\/00006565-199702000-00001"},{"key":"2025121219443429000_13.11.e079040.3","doi-asserted-by":"publisher","DOI":"10.1046\/j.1526-4610.2000.00004.x"},{"key":"2025121219443429000_13.11.e079040.4","doi-asserted-by":"crossref","first-page":"185","DOI":"10.1177\/0333102418781814","article-title":"Red flag findings in children with headaches: prevalence and association with emergency department neuroimaging","volume":"39","author":"Tsze","year":"2019","journal-title":"Cephalalgia"},{"key":"2025121219443429000_13.11.e079040.5","doi-asserted-by":"publisher","DOI":"10.1111\/j.1526-4610.2007.00782.x"},{"key":"2025121219443429000_13.11.e079040.6","doi-asserted-by":"publisher","DOI":"10.1111\/j.1526-4610.2007.01052.x"},{"key":"2025121219443429000_13.11.e079040.7","doi-asserted-by":"publisher","DOI":"10.1007\/s10194-008-0014-1"},{"key":"2025121219443429000_13.11.e079040.8","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2008-3150"},{"key":"2025121219443429000_13.11.e079040.9","doi-asserted-by":"publisher","DOI":"10.1016\/j.pediatrneurol.2013.10.005"},{"key":"2025121219443429000_13.11.e079040.10","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1016\/S1470-2045(22)00655-6","article-title":"Brain cancer after radiation exposure from CT examinations of children and young adults: results from the EPI-CT cohort study","volume":"24","author":"Hauptmann","year":"2023","journal-title":"Lancet Oncol"},{"key":"2025121219443429000_13.11.e079040.11","doi-asserted-by":"publisher","DOI":"10.1007\/s00247-002-0671-1"},{"key":"2025121219443429000_13.11.e079040.12","doi-asserted-by":"publisher","DOI":"10.2214\/ajr.176.2.1760289"},{"key":"2025121219443429000_13.11.e079040.13","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2019.11456"},{"key":"2025121219443429000_13.11.e079040.14","doi-asserted-by":"publisher","DOI":"10.1111\/j.1651-2227.2010.01728.x"},{"key":"2025121219443429000_13.11.e079040.15","doi-asserted-by":"publisher","DOI":"10.1046\/j.1526-4610.2000.040008629.x"},{"key":"2025121219443429000_13.11.e079040.16","doi-asserted-by":"publisher","DOI":"10.1111\/j.1460-9592.2009.03023.x"},{"key":"2025121219443429000_13.11.e079040.17","doi-asserted-by":"publisher","DOI":"10.1111\/j.1526-4610.2006.00371.x"},{"key":"2025121219443429000_13.11.e079040.18","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2013-0299"},{"key":"2025121219443429000_13.11.e079040.19","doi-asserted-by":"crossref","first-page":"S78","DOI":"10.1016\/j.jacr.2018.03.017","article-title":"ACR appropriateness criteria \u00ae headache\u2013child","volume":"15","author":"Hayes","year":"2018","journal-title":"Journal of the American College of Radiology"},{"key":"2025121219443429000_13.11.e079040.20","doi-asserted-by":"publisher","DOI":"10.1111\/j.1526-4610.2011.01845.x"},{"key":"2025121219443429000_13.11.e079040.21","doi-asserted-by":"publisher","DOI":"10.1097\/PEC.0000000000000074"},{"key":"2025121219443429000_13.11.e079040.22","doi-asserted-by":"publisher","DOI":"10.1148\/radiology.202.3.9051039"},{"key":"2025121219443429000_13.11.e079040.23","doi-asserted-by":"crossref","first-page":"208","DOI":"10.1016\/j.pedneo.2013.09.008","article-title":"Headache in the pediatric emergency service: a medical center experience","volume":"55","author":"Hsiao","year":"2014","journal-title":"Pediatr Neonatol"},{"key":"2025121219443429000_13.11.e079040.24","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2009-0254"},{"key":"2025121219443429000_13.11.e079040.25","doi-asserted-by":"publisher","DOI":"10.1177\/0009922808323110"},{"key":"2025121219443429000_13.11.e079040.26","doi-asserted-by":"publisher","DOI":"10.1177\/0883073807308692"},{"key":"2025121219443429000_13.11.e079040.27","doi-asserted-by":"crossref","first-page":"413","DOI":"10.1542\/peds.96.3.413","article-title":"The value of brain imaging in children with headaches","volume":"96","author":"Maytal","year":"1995","journal-title":"Pediatrics"},{"key":"2025121219443429000_13.11.e079040.28","doi-asserted-by":"publisher","DOI":"10.1046\/j.1526-4610.2000.00029.x"},{"key":"2025121219443429000_13.11.e079040.29","doi-asserted-by":"publisher","DOI":"10.1001\/archpedi.1982.03970380033008"},{"key":"2025121219443429000_13.11.e079040.30","doi-asserted-by":"crossref","first-page":"459","DOI":"10.1097\/PEC.0000000000001347","article-title":"Clinical factors associated with pediatric brain Neoplasms versus primary headache: a case-control analysis","volume":"36","author":"Sheridan","year":"2020","journal-title":"Pediatr Emerg Care"},{"key":"2025121219443429000_13.11.e079040.31","doi-asserted-by":"publisher","DOI":"10.1007\/s10194-005-0168-z"},{"key":"2025121219443429000_13.11.e079040.32","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1111\/j.1526-4610.1983.hed2301015.x","article-title":"Changes in the prevalence of migraine and other headaches during the first seven school years","volume":"23","author":"Sillanp\u00e4\u00e4","year":"1983","journal-title":"Headache"},{"key":"2025121219443429000_13.11.e079040.33","doi-asserted-by":"publisher","DOI":"10.1001\/archneur.1992.00530250083020"},{"key":"2025121219443429000_13.11.e079040.34","doi-asserted-by":"publisher","DOI":"10.1136\/adc.2009.162057"},{"key":"2025121219443429000_13.11.e079040.35","doi-asserted-by":"publisher","DOI":"10.3928\/00904481-20100623-05"},{"key":"2025121219443429000_13.11.e079040.36","doi-asserted-by":"publisher","DOI":"10.1001\/archneur.1993.00540020010003"},{"key":"2025121219443429000_13.11.e079040.37","doi-asserted-by":"crossref","first-page":"700","DOI":"10.1001\/jamapediatrics.2013.311","article-title":"The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk","volume":"167","author":"Miglioretti","year":"2013","journal-title":"JAMA Pediatr"},{"key":"2025121219443429000_13.11.e079040.38","doi-asserted-by":"publisher","DOI":"10.1213\/ane.0b013e31818fc334"},{"key":"2025121219443429000_13.11.e079040.39","unstructured":"Pediatric Emergency Care Applied Research Network . About PECARN. Available: https:\/\/pecarn.org\/about\/ [Accessed 13 Jun 2023]."},{"key":"2025121219443429000_13.11.e079040.40","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1016\/j.jpeds.2020.02.018","article-title":"Interobserver agreement in the assessment of clinical findings in children with headaches","volume":"221","author":"Tsze","year":"2020","journal-title":"J Pediatr"},{"key":"2025121219443429000_13.11.e079040.41","doi-asserted-by":"publisher","DOI":"10.1055\/s-0038-1651496"},{"key":"2025121219443429000_13.11.e079040.42","doi-asserted-by":"crossref","unstructured":"Breiman L , Friedman JH , Olshen RA , et al . Classification and regression trees. New York, NY: Routledge, 2017. doi:10.1201\/9781315139470","DOI":"10.1201\/9781315139470"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2023-079040","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,13]],"date-time":"2025-12-13T03:44:45Z","timestamp":1765597485000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2023-079040"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,11]]},"references-count":42,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2023,11,22]]},"published-print":{"date-parts":[[2023,11]]}},"alternative-id":["10.1136\/bmjopen-2023-079040"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2023-079040","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,11]]}}}