associated with the administration of contrast material However, obtaining a nonemergent MRI from the ED may not be an available option What then is the appropriate diagnostic approach? Certainly, having a clinical pathway in place may be helpful for arranging efficient and timely outpatient care In general, a child with headaches who is suspected of having a brain tumor should undergo a head CT scan in the ED if there are any signs or symptoms of elevated ICP or mass effects These include an altered mental status, visual changes, persistent vomiting, papilledema, or focal neurologic deficits Because tumors that cause elevated ICP or mass effects are usually larger and more easily detectable, the reduction in image resolution with CT is less likely to result in missing an abnormality in such cases Of note, if the CT scan is normal in a child with headache and new focal deficits on neurologic examination, it may be necessary to obtain an emergent MRI to exclude the diagnosis of stroke (e.g., arterial dissection), although this may simply represent the first presentation of a complex migraine syndrome But what about the child with a suspicious history (e.g., increasing frequency or duration of pain, headaches that awaken the child from sleep or occur every morning) who has a normal neurologic examination and no signs of elevated ICP? In most cases, if MRI is not available for a nonemergent scan from the ED, such patients can be safely discharged with an outpatient MRI scheduled shortly thereafter In such cases, parents must be clearly instructed that any sign of deterioration, such as mental status changes or persistent vomiting, requires that the child be immediately returned to the ED for a reevaluation Suggested Readings and Key References Brna PM, Dooley JM Headaches in the pediatric population Semin Pediatr Neurol 2006;13(4):222–230 de Ribaupierre S, Rilliet B, Cotting J, et al A 10-year experience in paediatric spontaneous cerebral hemorrhage: which children with headache need more than a clinical examination? Swiss Med Wkly 2008;138(5–6):59–69 Genizi J, Khourieh-Matar A, Assaf N, et al Occipital headaches in children: are they a red flag? J Child Neurol 2017;32(11):942–946 Expert Panel on Pediatric Imaging; Hayes LL, Palasis S, Bartel TB, et al ACR Appropriateness Criteria® headache—child J Am Coll Radiol 2018;15(5S):S78–S90 Hershey AD Pediatric headache Pediatr Ann 2005;34:426–429 Honig PJ, Charney EB Children with brain tumor headaches: distinguishing features Am J Dis Child 1982;136:121–141