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.
A thorough evaluation of the binocular vision and accommodative systems can be fruitful in a child with headaches. A full assessment of these systems with normal values is summarized in Table 1.3
Related: The case of the single fixed pupil
First, assess ocular alignment. A significant phoria (with poor vergence ranges) can be the cause of headache. Note these common binocular conditions that are frequently associated with headaches:
Convergence insufficiency: Exophoria greater at near
Convergence excess: Esophoria greater at near
Divergence excess: Exophoria greater at distance
Ensure you are vigilant with your cover test. The presence of a strabismus should trigger the examiner to perform comitancy testing—evaluating the deviation in multiple positions of gaze. An incomitant strabismus indicates a muscle (mechanical) or nerve (neurologic) problem. A forced duction test can be used to differentiate between these two causes. The presence of a cranial nerve palsy can often be seen during extraocular motility testing, so watch carefully. Typically, a patient with a new-onset strabismus would complain of diplopia, but children often do not complain of this unless specifically asked.
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