Study: Adolescents with migraines associated with binocular vision difficulties

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A cross-sectional study published September 4, 2026, in Ophthalmic and Physiological Optics found that Norwegian adolescents with migraine were associated with presence of binocular vision problems, including reduced convergence and accommodation.

The study, led by first author Hanne Mari Schiøtz Thorud, PhD, Professor at the University of South Norway’s Department of Optometry, Radiography, and Lighting Design, aimed to examine the association between untreated vision problems and headaches in adolescent children. The study authors attributed the gap in this area of research to “variability in study designs and the differing criteria employed for headache and vision assessment,” in previous studies.¹ The authors also highlight the necessity for comprehensive eye examinations in adolescent patients experiencing headaches.¹

“Adolescents with migraine characteristics were more likely to have untreated binocular vision and accommodative dysfunctions than their peers. Optometrists should ensure that headache evaluations include careful assessment of accommodation and vergence function, as comprehensive eye examinations may contribute valuable information to the management of adolescents with recurrent headaches,” the study authors told Optometry Times.

Background

Across all ages, headache disorders are one of the top 3 contributors of years lived with disability, with prevalence continuing to rise, according to data collected from 1990-2021.^2,3 Despite this burden, research on non-pharmacological management options for adolescent headaches remains limited. The current study evaluated the potential contribution of undetected vision problems to headache classification and severity.

Prior research found that 10-40% of school-aged children are likely to have “undetected and untreated vision problems,” according to study authors.^4-9 Convergence and accommodative insufficiency are recognized causes of visual difficulties in children.^10-11 Binocular vision disorders, such as strabismus and astigmatism, are also referenced in international clinical guidelines as conditions associated with headache.^12-14 However, headache management treatment for children and adolescents remain predominantly pharmacological, with limited incorporation of comprehensive vision assessment into standard pediatric workups.¹

Study overview

The study enrolled 230 students in the 10th grade (mean age, 15.5 ± 0.5 years) at 2 lower secondary schools in Kongsberg municipality, Norway, during the 2021–2022 and 2022–2023 school years. Participants completed a structured questionnaire allowing headache classification per the International Classification of Headache Disorders, 3rd edition (ICHD-3). Pain intensity was rated using the Wong-Baker FACES Pain Rating Scale. The questionnaire also captured upper body pain/discomfort, screen time, and physical activity. A vision testing program, conducted by optometrists and supervised optometry students, visual tests for point of convergence (NPC), ocular biometry, and monocular amplitude of accommodation. While the vision testing program included a variety of baseline metrics, it was not a comprehensive eye exam. Clinicians performing vision assessments were blinded to headache classification data. The primary end points were headache type classification and associations between headache diagnosis and specific vision findings.¹

Results

Overall, 190 of 230 participants (83%) reported headache on an average of 5.4 ± 5.9 days per month (mean ± SD). Frequent tension-type headache (TTH) was classified in 42 (18%) and migraine in 25 (11%), consistent with published prevalence estimates for this age group.^1,4

Within the cohort, 32% of the cohort (n = 74) had an uncorrected or mis-corrected vision problem. Adolescents in this group were significantly more likely to receive a migraine classification compared with those with normal or corrected-to-normal vision (20% vs. 8%; P = 0.009). They also reported more arm/wrist/hand pain or discomfort (68% vs. 49%; P = 0.007). Among participants classified with migraine, reduced binocular vision (37% vs. 16%, P = 0.008), accommodation amplitude (15% vs. 2%, P = 0.009), and near point of convergence (19% vs. 2%, P < 0.001) was observed.¹

Additionally, participants reporting arm/wrist/hand pain more often had reduced near point of convergence (NPC) compared with those without such pain (12% vs. 3%; p = 0.02). Screen time (mean, 8.1 hours/day) and physical activity (mean, 2.1 hours/day) were not significantly associated with headache classification.¹

Findings, strengths, and limitations

The study found a significant association between migraine diagnosis and factors causing near visual function difficulties, such reduced NPC and accommodation amplitude. However, the cross-sectional design of the study prevents the ability to draw casual inference from the results. The questionnaire did not include questions sufficient to classify migraine with aura per ICHD-3 criteria. The study was also unable to classify participant symptoms as ICHD-3’s criterion C (evidence of causation). The scale item requires follow-up from participants to determine a casual relationship. “Additional questions and interviews of the participants might have been necessary to make [a migraine] diagnosis," the study authors stated on this limitation. Sub-group analyses were limited by small cell sizes (15 adolescents with migraine in the uncorrected group; 12 in the control group), reducing statistical power.¹ The authors note that the inclusion of cycloplegic refraction testing to evaluate refractive errors is a “major strength” of the study.^1,15,16 “A comprehensive eye examination may offer significant benefits and should be considered an integral part of the management strategy for patients with headaches,” the study authors recommended.¹

References

1. Thorud HMS, Bjørset CO, Minsås IHH, et al. Migraine and reduced binocular vision in adolescents: a cross-sectional study. Ophthalmic Physiol Opt. 2026. doi:10.1007/s44402-026-00180-7

2. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1204–1222. doi: 10.1016/S0140-6736(20)30925-9

3. GBD 2021 Diseases and Injuries Collaborators. Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet. 2024;403(10440):2133–2161. doi:10.1016/S0140-6736(24)00757-8

4. Falkenberg HK, Langaas T, Svarverud E. Vision status of children aged 7-15 years referred from school vision screening in Norway during 2003-2013: a retrospective study. BMC Ophthalmol. 2019;19:180. doi:10.1186/s12886-019-1178-y.

5. Hagen LA, Gilson SJ, Baraas RC. Vision status and reading test results in adolescents in Norway. Scand J Optom Vis Sci. 2020;13:2–7. doi:10.5384/sjovs.vol13i2p2-7.

6. Junghans B, Kiely PM, Crewther DP, Crewther SG. Referral rates for a functional vision screening among a large cosmopolitan sample of Australian children. Ophthalmic Physiol Opt. 2002;22:10–25. doi:10.1046/j.1475-1313.2002.00010.x.

7. Bodack MI, Chung I, Krumholtz I. An analysis of vision screening data from New York City public schools. Optometry. 2010;81:476–84. doi:10.1016/j.optm.2010.05.006

8. White SLJ, Wood JM, Black AA, Hopkins S. Vision screening outcomes of Grade 3 children in Australia: differences in academic achievement. Int J Educ Res. 2017;83:154–9. doi:10.1016/j.ijer.2017.03.004

9. Mahayana IT, Indrawati SG, Pawiroranu S. The prevalence of uncorrected refractive error in urban, suburban, exurban and rural primary school children in Indonesian population. Int J Ophthalmol. 2017;10:1771–6. doi:10.18240/ijo.2017.11.21

10. Junghans BM, Azizoglu S, Crewther SG. Unexpectedly high prevalence of asthenopia in Australian school children identified by the CISS survey tool. BMC Ophthalmol. 2020;20:408. doi:10.1186/s12886-020-01642-3

11. Nunes AF, Monteiro PML, Ferreira FBP, Nunes AS. Convergence insufficiency and accommodative insufficiency in children. BMC Ophthalmol. 2019;19:58. doi:10.1186/s12886-019-1061-x

12. Coats DK, Paysse EA. Evaluation and management of strabismus in children: UpToDate. Updated August 10, 2026. Accessed September 14, 2026. https://www.uptodate.com/contents/evaluation-and-management-of-strabismus-in-children?search=strabismus&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

13. Salchow DJ. Strabismus: BMJ Best Practice. Published May 29, 2026. Accessed September 14 2026. https://bestpractice.bmj.com/topics/en-gb/689?q=Strabismus&c=recentlyviewed

14. Bakshi E, Zadok D. Astigmatism: BMJ Best Practice. 2026. Published September 21, 2023. Accessed September 14, 2026. https://bestpractice.bmj.com/topics/en-gb/762?q=Astigmatism&c=suggested

15. Bjorset CO, Pedersen HR, Synstelien GO, et al. Non-cyclopegic refraction cannot replace cycloplegic refraction when screening for refractive errors in children. Scan J optom Vis Sci. 2022; 15:6 doi:10.15626/sjovs.v15i2.3645

16. Morgan IG, Iribarren R, Fotouhi A, Grzybowski A. Cycolplegic refraction is the gold standard for epidemiological studies. Acta Opthalmol. 2015;93:581-5. doi:10.1111/aos.12642