Children’s Drawings of Their Headaches May Indicate Migraine

VANCOUVER—When children depict themselves having a headache, the presence of visual phenomena in their drawings predicts a diagnosis of migraine, according to a study described at the 45th Annual Meeting of the Child Neurology Society. In addition, although drawings by children with migraine and children with pseudotumor cerebri tend to have similar features, depictions of diplopia are much more common among children with pseudotumor cerebri, researchers said.

Migraine affects between 2% and 11% of children, and visual auras are the most prevalent symptom in patients with migraine with aura. Prior studies have found that children’s headache drawings can distinguish migraine from nonmigraine headaches based on the location and quality of pain, presence of nausea or vomiting, visual symptoms, and other features.

To determine whether children’s drawings of visual phenomena predict migraine diagnosis, Carl E. Stafstrom, MD, PhD, Professor of Neurology and Director of Pediatric Neurology, and Erica B. Lee, an undergraduate student, both at Johns Hopkins University School of Medicine in Baltimore, examined drawings by 675 patients from ages 6 to 18. The study included drawings by 498 children with migraine, 155 children with tension-type headache, and 22 children with pseudotumor cerebri.

Carl E. Stafstrom, MD, PhD

Before providing a history, patients received a blank piece of paper and 12 colored pencils. Patients were asked to “Please draw a picture of yourself having headache,” without any leading questions. Examiners often asked patients to describe the pictorial features in their drawings and then conducted the usual history, examination, formulation, and management plan.

Visual symptoms included positive phenomena (eg, zigzags or spots), visual field defects, and blurring or tunnel vision. Of the children with migraine, 37.1% depicted visual symptoms in their drawings, compared with 4.5% of children with tension-type headache and 27.3% of children with pseudotumor cerebri. The positive predictive value of visual phenomena for a migraine diagnosis was 96.4%.

Among patients with pseudotumor cerebri, 18.2% depicted diplopia, compared with 0.9% of patients with migraine and 0.6% of patients with tension-type headache.

Dr. Stafstrom and Ms. Lee said that patient artwork is vastly underused in pediatric neurology, and they encouraged clinicians to adopt “this simple, enjoyable, inexpensive, noninvasive method” to support headache differential diagnosis in conjunction with diagnostic criteria and laboratory studies. “Drawings allow self-expression and afford insights into both medical and psychological aspects of a child’s illness experience that are often not expressed by the patient or parent or recognized by the clinician,” they concluded.

To see examples of the children’s drawings, click here.

—Jake Remaly

Suggested Reading

Schott GD. Exploring the visual hallucinations of migraine aura: the tacit contribution of illustration. Brain. 2007;130(Pt 6):1690-1703.

Stafstrom CE, Rostasy K, Minster A. The usefulness of children’s drawings in the diagnosis of headache. Pediatrics. 2002;109(3):460-472.