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.
When to image?
The American Academy of Neurology and the Child Neurology Society published recommendations regarding neuroimaging as part of evaluation of headache in children and adolescents in 2002.5
Its recommendations are as follows:
- On a routine basis, neuroimaging is not indicated in children with recurrent headaches and a normal neurologic exam
- Neuroimaging can be considered in children with an abnormal neurologic exam, the coexistence of seizures, or both
- Neuroimaging can be considered in children who have historical data to suggest recent onset of severe headaches, change in type of headache, or associated factors suggestive of neurologic dysfunction
Another study looked at children who presented to the emergency department with the complaint of headaches and what signs or symptoms were most associated with them having a brain neoplasm versus clean neuroimaging.6 The findings show that the following were significant: neurologic signs (10.3x greater chance of neoplasm present), seizure (10.8x) and vomiting (6.6x). So, it is important to remember that neurologic signs and symptoms play a significant role in the decision to image a pediatric headache patient.
Although neurologists conduct a cursory evaluation of visual acuity, pupils, visual field, extraocular motilities, and gross funduscopic exam, this is optometrists’ specialty area. ODs are poised to evaluate the visual system and provide input on ocular neurologic signs that they may see. It is important to remember these neurologic findings should be communicated to the neurologist in order to facilitate neuroimaging. Or, if you are able, imaging can be ordered yourself due to:
- Acutely reduced visual acuity with no apparent cause
- New-onset anisocoria or the presence of an afferent pupillary defect
- Cranial nerve palsy
- Neurologic visual field loss
- Non-ocular headache management
1. Lateef TM, Merikangas KR, He J, et al. Headache in a national sample of American children: prevalence and comorbidity. J Child Neurol. 2009 May;24(5):536-43.
2. Blume HK. Childhood headache: a brief review. Pediatr Ann. 2017 Apr 1;46(4):e155-e165.
3. Scheiman M, Wick B. Clinical Management of Binocular Vision: Heterophoric, Accommodative, and Eye Movement Disorders. Philadelphia: Lippincott Williams & Wilkins, 2013.
4. Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol. 2008;126(10):1336-1349.
5. Scheiman M, Cotter S, Kulp MT, et al. Treatment of Accommodative Dysfunction in Children: Results from a Randomized Clinical Trial. Optom Vis Sci. 2011;88:1343–52.
6. Lewis DW, et al. Practice parameter: Evaluation of children and adolescents with recurrent headaches: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2002 Aug 27;59(4):490-8.
7. Sheridan DC, Waites B, Lezak B, et al. Clinical factors associated with pediatric brain neoplasms versus primary headache: a case-control analysis. Pediatr Emer Care. 2017 Nov 14. doi: 10.1097/PEC.0000000000001347.