Optometrists play an important role in evaluating children who present with headaches. A comprehensive assessment is required to rule out neurologic signs, ocular pathology and binocular vision or accommodative dysfunction. Communicating findings to the patient’s medical doctor is also key.
The ocular exam
Just like any other examination, a headache evaluation begins with the basics: visual acuity, pupils, and extraocular motility testing. The following findings during assessments of these systems would be causes for alarm and would warrant further investigation:
Visual acuity that is reduced with no apparent refractive, amblyopic, or pathologic cause
Presence of anisocoria (non-physiologic) or an afferent pupillary defect
Restriction of movement on extraocular motility testing
A comprehensive evaluation of a headache patient should include an assessment of ocular health and visual field (automated if the patient is able). Visual field is an important tool to evaluate the integrity of the visual pathway. Neurologic visual field loss (such as homonymous hemianopsia, bitemporal hemianopsia) would indicate a likely organic cause of headache. Increased intraocular pressure (IOP) and anterior and/or posterior segment inflammation should be ruled out as a cause of pain that may be interpreted as headache by a child. The most ominous ocular finding to rule out is papilledema, which indicates increased intracranial pressure.
While it is important to rule out ocular signs of emergent headaches, in my experience the exam is much more likely to find that a secondary headache with ocular etiology is caused by something easily diagnosed and treated within an optometric office.
Foremost, refractive error must be evaluated. Myopia and astigmatism are typically easy to detect, but hyperopia can be a little trickier. In some children, even small amounts of hyperopia can cause headaches. This hyperopia may be latent and not be apparent until the patient is cyclopleged (1% cyclopentolate recommended). In a headache patient, prescribing even low amounts of hyperopia is warranted to rule out that their refractive error may be the headache trigger.
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