What is a headache?
What causes a headache related to the eye?
Who gets a headache?
How does it cause disease?
What are the common findings?
How is a headache diagnosed?
How is a headache treated?
What are the complications?
How is a headache prevented?
Robert A. King, M.D.
The Children's Hospital
Commonly described, a headache is pain in the head. Generally, a headache is not
dangerous; however, it can be a symptom of an underlying ocular problem or a serious
The following conditions related to the eye may cause a headache:
Typically, when a child complains of a headache to a pediatrician that may be attributed
to eye fatigue and/or eyestrain, the child is referred to a pediatric ophthalmologist,
a doctor who specializes in eye care and surgery for children. With the pediatrician,
the pediatric ophthalmologist helps to diagnose and treat the child.
Children often complain of headaches. Most commonly, these children are aged from
2 years to 19 years, with an average age of 10 years. Migraine headaches occur in
2.7% of children by age 7 and in 10.9% of children by age 14; onset in children
by age 4 is not uncommon. Headaches caused by convergence or accommodative insufficiency
usually do not occur until school age and often not until third or fourth grade
when the reading print becomes smaller and it takes a longer time to finish assignments.
A headache is a symptom of a problem, not a disease in its own right. The conditions
listed above can be ocular causes of headaches. Headache itself does not cause medical
damage, but one of the above listed conditions may cause it.
Convergence insufficiency usually occurs in the school-aged child who complains
of a chronic headache, typically for several months. The child may have difficulty
with learning to read; in particular, the child may hold reading material close
to the face in an attempt to overcome the blurry vision. This process usually overtaxes
already weak convergence amplitudes, which are a measure of a person's ability to
focus both eyes simultaneously on a reading target. The problem may occur several
times a week, if not daily, and may occur in school or with homework, with relief
on weekends or vacations. The child does not complain of headaches that awaken the
child from sleep or of headaches that occur upon awakening in the morning. Nausea
and vomiting do not occur with this condition. The child may complain of double
vision or may be seen closing or covering one eye, presumably to avoid double vision.
The signs and symptoms of this condition are exactly the same as convergence insufficiency.
The child may complain of blurry vision or may simply complain of headache with
or after reading. Sometimes, accommodative spasm may be the diagnosis. In this situation,
the child becomes focused excessively at near, actually locking the eyes in this
focused position. Blurry vision occurs when the eyes are raised to look in the distance.
Migraine is a common form of headache in children. Because of the frequently associated
visual disturbances, children with migraine often are referred to a pediatric ophthalmologist.
Migraine is classified as classic migraine, or migraine with aura; common migraine,
or migraine without aura; and complicated migraine.
Migraine with Aura
Migraine with aura begins with the appearance of focal neurologic symptoms, such
as numbness in a limb or facial paralysis on one side. Typically, visual symptoms
last from 4 to 60 minutes (not seconds or days). Classically described, these symptoms
are jagged lines of light surrounding a central blind spot that expand to the peripheral
visual field. A child may describe visual symptoms as colorful, bright, flickering,
turning, and moving. Some children may describe a kaleidoscope-like effect. Younger
children who may not be able to describe these findings should be encouraged to
Migraine auras generally are followed by an intense, pounding headache located on
one side of the head that lasts from two to four hours. The child typically will
seek rest, without encouragement, in a quiet, dark room.
Migraine Without Aura
This condition is not associated with preceding visual symptoms. Instead, poorly
defined symptoms, generally characterized by behavioral or gastrointestinal disturbances,
precede the headache attack by hours to days. The headache begins on one side of
the head but often spreads to the whole head, typically lasting hours to several
days. Nausea and vomiting, photophobia (avoiding light), and phonophobia (avoiding
noise or even sound) are more frequent in this type of migraine than in migraine
This condition is associated with other neurologic phenomenon, including the ophthalmoplegic
migraine, where the patient is unable to move an eye from side to side. Such a condition
can occur in children, and it is characterized by periodic episodes of ophthalmoplegia,
beginning at the peak of the headache and involving all functions of the oculomotor
nerve. The headache usually occurs on the same side and is located around the orbit
of the eye. The weakness may last for several weeks after the resolution of the
An unusual form of complicated migraine is the Alice in Wonderland syndrome. Alterations
in time and body image, as well as visual distortions, such as shrinking, enlargement,
inversion, and elongation, characterize this syndrome.
Strabismus is defined as misalignment of the eyes. With this condition, the eyes
can cross (esotropia), turn out (exotropia), or undergo vertical deviation (hypertropia).
Any strabismus may cause headaches, with the same signs and symptoms as convergence
insufficiency; however, strabismus diagnosed by the ophthalmologist differentiates
the two conditions. Frequently, the parents may notice that the child covers or
squints one eye with either reading or distance activity or both. Presumably, this
action occurs because the child is attempting to avoid having double vision. A history
of head trauma or other specific inciting event may result in nerve palsy of one
of the nerves (i.e., cranial nerves III, IV, and VI) that move the eye muscles.
Refractive errors are the optical condition of the eyes that cause blurry vision,
which clears by wearing glasses. Astigmatism and farsightedness are the two refractive
errors that may cause a child to experience focusing problems, leading to fatigue
and then headache. Astigmatism is when the front surface of the eye is shaped less
like a sphere and more like an egg when one meridian is distorted. Farsightedness
(hyperopia) is the optical condition when the eye is too short for the focusing
system, thereby forcing the patient to excessively focus the lens of the eye (accommodate)
to bring images to focus on the retina of the eye. The child often complains of
headaches on school days or after long periods of reading when focusing effort has
been at a maximum; no headaches occur when the child is not reading. A child with
significant astigmatic error may hold reading material too close to the face simply
because the words look blurry. This action, in turn, demands that the child accommodate
more and converge more to be able to read. If the child holds reading material too
close for too long, even normal accommodative and convergence amplitudes are inadequate
to sustain long periods of reading.
Increased Intracranial Pressure
A child experiencing a headache that is caused by a brain tumor is quite significant.
Classic findings include headaches that awaken the child at night, nausea and vomiting
with the headache, and frequently accelerating symptoms over a relatively short
time. Recurring morning headaches may be significant; however, this finding also
may be related to sinus disease. Additionally, the child may complain of double
vision (diplopia), jiggling vision (oscillopsia), or blurry vision. Pseudotumor
cerebri is elevated pressure in the head that is not associated with an anatomic
cause, such as a brain tumor or hydrocephalus. It occurs in children with prior
head trauma, in children who are taking Accutane for acne, or in children who are
taking prednisone, for example as part of a chemotherapy regimen. In some teenagers,
this condition may occur without any reason.
A child may complain of headaches that result from an unusual diagnosis, such as
albinism or nystagmus. Albinism is a specific ocular disorder caused by decreased
body pigment in the skin and in the eye, where vision is decreased because the retina
has a deficiency of cells. Nystagmus, which is best characterized as " jiggling
eyes," results because the vision is poor or because of a primary motor instability
that is congenital in nature. Nystagmus also can be caused by other entities.
The history is especially important in assessing whether the headaches occur with
reading or other near effort. A child with albinism complaining of headaches may
experience eyestrain by holding reading material close to the face, because of the
poor vision. A child with nystagmus of any cause may hold reading material close
to the face because it dampens the nystagmus (reduces the jiggling) and enlarges
To determine the cause of a headache relating to each of the above listed conditions,
a history of the circumstances surrounding the headache and associated symptoms,
a physical examination for neurological abnormalities, and an ocular examination
should all be performed. The history is very important from both the parents and
the child. The time course of the headache should be recorded. The frequency and
the circumstances in which the headache occurs also may be important; for example,
a headache may occur in school after the child reads for 15 minutes.
Associated symptoms should be explored. The pediatric ophthalmologist should be
informed of other physicians who have examined the child; other tests that have
been performed; other medical problems of the child; and other signs or symptoms
observed by the parents, such as abnormal head positions, closing one eye, vomiting,
redness, or swelling.
The eye examination is important. The pediatric ophthalmologist will check the child's
visual acuity (how the child reads the eye chart) at distance and near, with one
eye at a time (monocular) and with both eyes simultaneously (binocular). The child's
eye alignment will be recorded in all positions of gaze (looking in every direction)
and with left and right head tilt. Accommodative and convergence amplitudes will
be measured, and the refractive error will be determined frequently after using
dilating drops. The pediatric ophthalmologist will perform a slit lamp examination
and a funduscopic examination, with close observation of the optic nerve, examining
it for evidence of increased intracranial pressure.
Further diagnostic testing generally is not necessary. However, in the case of complicated
migraine, glucose tolerance testing to rule out diabetes or neuroimaging (a CT scan
or MRI scan of the head) to rule out serious intracranial pathology may be required.
With other conditions (for example, strabismus or increased intracranial pressure),
neurological testing, including neuroimaging, may be required.
To treat this condition, the pediatric ophthalmologist may prescribe a trial of
patching with reading. The patch overcomes any strain induced by attempting to use
the eyes together. If reading improves or if the headaches decline in frequency,
magnitude, or duration with an eye patch, then the eyestrain induced by the effort
to focus is being relieved.
Treatment for this condition is aimed at avoiding the problem or increasing reduced
convergence amplitudes. If the child holds reading material too close to the face,
then the reduced convergence amplitudes will cause eye fatigue/headaches in a shorter
time frame. Therefore, holding reading material further from the face often is helpful.
Exercises can be done to improve reduced convergence amplitudes. Convergence amplitudes
are measured using a prism bar. When the amplitudes fall well below the normal range,
exercises should be done. The exercises normalize reduced amplitudes. Relieving
convergence insufficiency is the single most useful application of eye exercises.
Parents can begin this exercise with the aid of an orthoptist, who can train and
instruct both the parents and the child. The parents should record feedback from
this exercise. Two sessions of exercises, each lasting six to eight weeks, usually
is recommended. The exercise can be performed at home, 15 minutes per day, with
the supervision of an orthoptist once a month. The child should not have to enroll
for a year of vision therapy. The end point of treatment for this condition is normalization
of convergence amplitudes and/or relief of symptoms.
Measuring accommodative amplitudes is part of the eye examination. The near point
of accommodation can be excessively recessed. Reading glasses are used to move the
near point of accommodation close to the face. To treat this condition, it is recommended
that the parents buy an inexpensive pair of over-the-counter reading glasses for
the child to wear when reading. The headaches may resolve by either the placebo
effect of the glasses or true accommodative insufficiency. In either case, the parent
may choose to have a formal pair of bifocal glasses prescribed by the pediatric
The best treatment for migraine includes reassurance, avoidance of precipitating
factors, abortive therapy, and prophylactic treatment. Abortive therapy includes
rest with or without the use of acetaminophen, anti-inflammatory drugs, or antiemetics.
Prophylactic treatment, including beta-blockers, calcium channel blockers, or antidepressants,
may be indicated for frequent, incapacitating headaches.
Treatment is directed at alleviating strabismus with glasses (with or without a
bifocal), prism glasses, occlusion (patching the eye), or surgery. When the patient
has accommodative esotropia, a hyperopic glasses prescription will alleviate the
crossing of the eyes and the headaches. Prism glasses are used occasionally to optically
align the eyes for small amounts of strabismus. Surgery to realign the eyes is ultimately
required in numerous strabismus conditions. The mechanical realignment by moving
the muscles that move the eyes is often the only treatment to relieve double vision.
For a child who is farsighted (hyperopic) or nearsighted (myopic) or who has astigmatism,
glasses are required. More complicated combinations of hyperopic, myopic, astigmatic,
or anisometropic refractive error require formal glasses prescriptions from a pediatric
ophthalmologist. Bifocal glasses rarely are needed outside of accommodative insufficiency
or high accommodative convergence/accommodation ratio.
For the conditions related to increased intracranial pressure, such as brain tumors
or hydrocephalus, neurosurgical intervention is the ultimate treatment. Follow-up
care with a pediatric ophthalmologist is recommended to ensure that the optic nerve
returns to its normal appearance. Additionally, computerized visual field examinations
are beneficial and should be performed on a periodic basis. Any ongoing loss of
visual field indicates that the intracranial pressure is not being controlled; in
this case, intracranial pressure monitoring is indicated.
For the child with special conditions, such as albinism and nystagmus, strong reading
glasses may relieve this relative accommodative insufficieny.
In the case of increased intracranial pressure, the child may continue to complain
of headaches even after the appropriate treatments have been performed. Failure
to control the pressure can lead to ongoing optic nerve damage. Ultimately, the
child can become blind if the intracranial pressure is not controlled or if the
optic nerve is not protected.
Routine eye examinations with a pediatric ophthalmologist are recommended to ensure
that any significant eye abnormalities are diagnosed and treated appropriately.
To prevent migraine headaches, such precipitating factors as stress, chocolate,
nitrates, certain cheeses, and monosodium glutamate (flavor enhancer) should be
avoided. Additionally, in girls, oral contraceptives may worsen migraine headaches.
Honig PJ, Charney EB. Children with brain tumor headaches. Distinguishing features. Am J Dis Child. 1982 Feb;136(2):121-4.
Hupp SL, Kline LB, Corbett JJ. Visual disturbances of migraine. Surv Ophthalmol 1989 Jan-Feb;33(4):221-36.
King RA. Common ocular signs and symptoms in childhood. Pediatr Clin North Am 1993 Aug;40(4):753-66.
Mapstone T. Brain tumors in children. In: Tomsak RT, ed. Pediatric Neuro-ophthalmology. Newton: Butterworth-Heinemann Medical; 1995:79.
McManaway JW. Management of common pediatric neuro-ophthalmology problems. In: Wright KW, ed. Pediatric Ophthalmology and Strabismus. St. Louis: Mosby-Year Book; l995:63.
Moore A. Hydrocephalus. In: Taylor D, ed. Pediatric Ophthalmology. London: Blackwell Scientific; 1990:499.
Nelhaus G, Stumpf DA, Moe PG. Neurologic and muscular disorders. In: Kempe CH, Silver HK, O'Brien D, eds. Current Pediatric Diagnosis and Treatment. Los Altos: Lange Medical Publishers; 1984:653.
Troost BT. Migraine and other headache. In: Duane TD, Jaeger EA, eds. Clinical Ophthalmology. Philadelphia: Harper and Row; 1997.
About the Author
Dr. King graduated from the United States Air Force Academy in 1972, with a Bachelor
of Science degree. After spending 5 years in the Air Force, he went to medical school
at the University of Colorado, graduating in 1981. He completed ophthalmology residency
training at the University of Colorado in 1985, followed by a pediatric ophthalmology
fellowship at Wills Eye Hospital in Philadelphia in 1986. Since then he has been
in private practice in Denver, specializing in pediatric ophthalmology and adult
He has been involved in resident training at The Children's Hospital of Denver,
and with other resident training programs as well. Past positions include co-director
of pediatric ophthalmology at the Children's Hospital in Denver, President of the
Colorado Ophthalmological Society (now the Colorado Society of Eye Physicians and
Surgeons), medical board member, and co-medical director of Anchor Center for Blind
Children. He has been a regular contributor at the National Symposium for Nurse
Practitioners, most recently chairing a symposium on the pediatric fundoscopic exam
in July 2001. He has authored numerous articles in the field of pediatric ophthalmology.
Dr. King is married. He and his wife Carla have 2 children, Eric age 17 and Brian
Copyright 2012 Robert A. King, M.D., All Rights Reserved
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