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 vergence system should be assessed to evaluate capacity and flexibility. Normal vergence ranges are noted Table 1. But, it is important to always be mindful of Sheard’s criterion as well—the compensating vergence range (BO for exo, BI for eso) should be twice the blur value (or break value if no blur is present). Vergence facility is commonly overlooked, but an inability to change from a convergence to a divergence posture poses difficulty and can be symptomatic. Inadequate fusional vergence, with or without significant phoria, can cause headaches.
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The accommodative system evaluation should include assessment of magnitude, flexibility, and accuracy. This will help to diagnose common accommodative conditions associated with headache:
Accommodative insufficiency: Reduced accommodative amplitude, difficulty with minus lenses
Accommodative spasm: Over-accommodation; lead on monocular estimated method (MEM), difficulty with plus lenses
Accommodative infacility: Reduced accommodative facility with difficulty on plus and minus lenses
Accommodative fatigue: Inability to sustain accommodation; lag on MEM that increases with time, amplitude of accommodation that recedes with repetition
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