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The usefulness of children's drawings in the diagnosis of headache
Carl E Stafstrom1, Kevin Rostasy, Anna Minster
1Departments of Pediatrics and Neurology, Division of Pediatric Neurology, Floating Hospital for Children, New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA. stafstrom@neurology.wisc.edu
Insights
Children's headache drawings are a simple and effective tool for diagnosing migraine. These drawings show high accuracy in distinguishing migraine from other headache types in pediatric patients.
Area of Science:
- Pediatric Neurology
- Medical Diagnostics
- Child Psychology
Background:
- Headaches are a common complaint in children.
- Accurate differential diagnosis of headache types, particularly migraine, is crucial for effective management.
- Traditional diagnostic methods rely on clinical history and examination, which can be challenging in young children.
Purpose of the Study:
- To evaluate the utility of children's drawings in the differential diagnosis of headaches.
- To determine the sensitivity, specificity, and predictive value of headache drawings for identifying migraine in pediatric patients.
Main Methods:
- 226 children presenting with headaches were asked to draw their headache experience before clinical evaluation.
- Pediatric neurologists, blinded to clinical history, scored the drawings for migraine-specific features.
- Drawing-based diagnoses were compared against a gold standard clinical diagnosis.
Main Results:
- Headache drawings demonstrated high diagnostic accuracy for migraine, with a sensitivity of 93.1% and specificity of 82.7%.
- Drawings featuring specific migraine indicators (e.g., pounding pain, nausea, photophobia) had a positive predictive value (PPV) of over 80-90%.
- Non-migraine features like band-like pain or sadness in drawings did not reliably predict headache type.
Conclusions:
- Children's headache drawings serve as a simple, cost-effective adjunct for diagnosing headache types in pediatric populations.
- The high sensitivity and specificity of drawings support their integration into the routine evaluation of childhood headaches.
- Encouraging children to draw their headache can provide valuable diagnostic insights beyond traditional clinical assessment.
Objective:
To determine whether drawings can aid in the differential diagnosis of headaches in children.
Methods:
Before taking any history, 226 children who were seen consecutively for the evaluation of headache were asked to draw a picture to show how their headache felt. The pictures were then scored as migraine or nonmigraine by pediatric neurologists who were blinded to the clinical history. A clinical diagnosis of headache type was determined independently by another pediatric neurologist using the usual history and examination. The diagnoses of headache type based on the pictures drawn and the clinical findings obtained were then compared to calculate the sensitivity, specificity, and predictive values of the drawings for the diagnosis of migraine.
Results:
Children produced dramatic and insightful headache drawings. Compared with the clinical diagnosis (gold standard), headache drawings had a sensitivity of 93.1%, a specificity of 82.7%, and a positive predictive value (PPV) of 87.1% for migraine. That is, drawings that contained an artistic feature consistent with migraine (eg, pounding pain, nausea/vomiting, desire to lie down, periorbital pain, photophobia, visual scotoma) predicted the clinical diagnosis of migraine in 87.1% of cases. Predictive values were also calculated for specific migraine-associated features on drawings: artistic depiction of focal neurologic signs, periorbital pain, recumbency, visual symptoms (photophobia, scotomata), or nausea/vomiting had a PPV of >90% for migraine; severe or pounding pain had a PPV of >80% for migraine. Band-like pain was not predictive of migraine (PPV of 11.1%). Features on drawings such as sadness or crying did not differentiate migraine from nonmigraine headaches.
Conclusions:
Children's headache drawings are a simple, inexpensive aid in the diagnosis of headache type, with a very high sensitivity, specificity, and predictive value for migraine versus nonmigraine headaches. We encourage the use of drawings in the evaluation of any child with a headache, as an adjunct to the clinical history and physical examination.
