by Karen Blum
Contributing Writer, MedPage Today
October 20, 2016
BALTIMORE – In trying to determine whether children have a headache associated with pseudotumor cerebri syndrome (idiopathic intracranial hypertension) or migraine, physicians might find clues by asking patients to draw a picture of their headache, researchers said here.
In a study examining 520 drawings of headache done by patients ages 6 to 18, researchers at Johns Hopkins University School of Medicine found that children with pseudotumor cerebri were more likely to depict diplopia through features like crossed eyes or double images. Four of 22 (18.2%) patients with pseudotumor depicted diplopia features in their drawings, compared with just two of 498 (0.4%) patients with migraine, said the lead author, Erica B. Lee, an undergraduate student working with pediatric neurologist Carl E. Stafstrom, MD, PhD, in a poster presentation at the annual meeting of the American Neurological Association.
Most of the drawings by children with headaches were similar, Lee noted: "The only distinguishing feature was diplopia. If they depicted diplopia, like double vision, then it was indicative of pseudotumor cerebri. It makes sense, because diplopia is characteristic of pseudotumor cerebri due to increased intracranial pressure affecting cranial nerve VI."
Headaches associated with pseudotumor cerebri syndrome are difficult to distinguish from migraine or tension-type headache based solely upon headache characteristics, Lee explained. Both are present with similar clinical features such as photophobia, phonophobia, nausea, vomiting, and frontal, pressure-like pulsatile pain. The most common pseudotumor symptom after headache is diplopia, which affects about 42 percent of children.
In the study, before any history was obtained. patients presenting with headache were provided with a blank, unlined piece of paper and a set of 12 colored pencils. The children were asked to draw a picture of themselves having a headache, without any leading questions or additional instructions. The examiner would often ask the child for a fuller description of the pictorial features before conducting the usual history and examination and formulating a management plan.
Most headache drawing features were similar in pseudotumor and migraine pictures, illustrating scintillating scotomas, blurry vision, visual field defects, photophobia, pounding pain, nausea, and recumbency. However, diplopia was depicted significantly more often by pseudotumor patients, making diplopia "a useful distinguishing feature of pseudotumor drawings versus migraine drawings," the authors wrote.
Positive phenomena like spots or zig-zags were depicted by five of 22 (22.7%) pseudotumor patients and 124 of 498 (24.9%) migraine patients. Blurred or tunnel vision was depicted in one drawing (4.5%) by a pseudotumor patient and in 38 (7.6%) drawings by migraine patients. Photophobia was depicted by three (14.3%) pseudotumor patients and 58 (11.6%) migraine patients. Looking at pain, pounding, or exploding pain was depicted by 11 (50%) pseudotumor patients and by 160 (32.1%) migraine patients; pressure was depicted by three (13.6%) pseudotumor patients and by 30 (6%) migraine patients.
In addition, dizziness was featured in one drawing (4.5%) by a pseudotumor patient and in 32 (6.4%) drawings by migraine patients. Recumbency was drawn by two (9.1%) pseudotumor patients and 62 (12.5%) migraine patients. Phonophobia was drawn by one (4.5%) pseudotumor patient and 20 (4%) migraine patients.
The use of patient-generated art is "vastly underutilized" in medicine and in neurology in particular, said Stafstrom, who also asks for drawings from children experiencing seizures. Even children as young as four can draw some symptoms, he said.
"The drawings add an immense amount of information, because children are not often able to explain their symptoms in words," he told MedPage Today. "Having them draw a picture allows the self-expression of their feelings, their symptoms, their insights into their own disorder ... as well as the psychological aspects of how they're feeling. It's been an immensely interesting, useful project. This is just one tip of the iceberg in pseudotumor."
Lee and Stafstrom disclosed having no relevant relationships with industry.