Headaches in Kids: Is An Eye Exam Necessary?

From CHOP Expert Commentary

Monte D. Mills, MD

Posted: 07/02/2012

Children's Hospital of Philadelphia, Division of Ophthalmology

I would like to talk about when primary care practices should refer children with headaches for an eye examination.

Headaches in children are common. The first stop for these children will be to your office -- to understand the history of the headaches, the severity and nature of the headaches, family history, and to examine the child for common causes of headaches in childhood. But some of these children will be examined by you, that examination will be normal, and no obvious cause of the headaches will be found. It may be appropriate to refer these children for an ophthalmic examination with a pediatric ophthalmologist.

There are certain types of alarming headaches where it probably is not appropriate to refer them for a routine pediatric eye examination, and the child may need to go directly to an emergency room or to a pediatric neurologist. These would be:

• Severe headaches;
• Headaches that are increasing in severity and frequency;
• Headaches that are interfering with normal activities;
• Headaches that are associated with nausea and vomiting; and
• Headaches that occur during the night and awaken the child or occur early in the morning.

But for other types of headaches, if the general examination is normal and there is no obvious cause from the history, it would be appropriate for a pediatric ophthalmologist to examine these patients for certain eye abnormalities that may be associated with headaches.

What would we be looking for when these children come to pediatric ophthalmology? First, we will look at their vision and refraction to see whether there may be an uncorrected refractive error causing poor vision and requiring glasses, which may be the cause of the headaches and is easily treated.

Second, we will be looking at their eye alignment and assessing for the presence of strabismus. There are certain forms of strabismus, particularly convergence insufficiency, that may cause eye strain with reading and headaches and are treatable by an ophthalmologist.

Next, we will look at the slit-lamp examination under high-powered magnification to look for uveitis, ocular inflammation, glaucoma, and other causes of referred pain that may come from the eye but be felt by the child as headache.

We will be looking at the dilated fundus examination to see the optic nerve and retina to look for such problems as papilledema, diabetic retinopathy, hypertension, and other changes in the eye that may be related to the cause of the headaches.

Don't be surprised when many of these examinations come back normal. We expect many of these kids to have benign types of childhood headaches that do not cause eye problems. That should be reassuring to you and to the parents. Don't be surprised if the ophthalmologist feels that other studies may be indicated, including sinus imaging or other imaging studies, and suggests referral to a neurologist for certain types of headaches.