American Board of Internal Medicine (ABIM) Certification Practice Exam

What is an indicator for performing imaging in patients with secondary headaches?

1. New headache in patients younger than 5 years

2. Frequent headaches without associated symptoms

3. Headaches responsive to over-the-counter medication

4. Headaches worsening with postural changes

The correct answer is: New headache in patients younger than 5 years

Performing imaging in patients with secondary headaches is especially indicated when there is a new headache, particularly in specific age groups such as those younger than 5 years. This age group is notable because new-onset headaches in children can be indicative of underlying pathology that requires investigation, such as intracranial hypertension, tumors, or other structural abnormalities. Since children may have different headache patterns and etiologies than adults, the approach to management and investigation can differ significantly. In contrast, frequent headaches without associated symptoms, headaches responsive to over-the-counter medication, and headaches worsening with postural changes do not by themselves universally warrant imaging. While these situations may suggest certain patterns or types of primary headaches (such as tension or migraine), they are not strong indicators of potentially serious underlying conditions as is the case with new-onset headaches in younger patients. Thus, recognizing the significance of new headache presentations in the pediatric population helps guide clinicians toward making appropriate decisions about necessary diagnostic imaging.