Diplopia Depictions in Drawings May Distinguish Pseudotumor Cerebri From Pediatric Migraine

young girl doing homework
young girl doing homework
Evidence of diplopia in children's headache drawings may help clinicians distinguish between pseudotumor cerebri syndrome and migraine.

The illustration of headache symptoms through drawings may help clinicians distinguish between pseudotumor cerebri syndrome (PTCS) and migraine in pediatric patients, according to a small study published in Pediatric Neurology.

Investigators asked children age 6 to 18 attending a university hospital pediatric neurology clinic to draw an image of how their headache felt. The investigators compared drawings by children with clinically diagnosed migraine (n=518) with drawings by patients with clinically diagnosed PTCS (n=21) to determine potential differences in symptoms.

The drawings by patients with PTCS displayed symptoms such as recumbency (n=1), dizziness (n=1), photophobia (n=3), pressure-like pain (n=3), and pounding pain (n=11). Pictures of anvils, bombs, and hammers indicated the presence of severe pain.

In addition, blurring, scintillations, and scotomata represented positive visual phenomena in eight of the drawings, whereas field defects were represented as negative visual phenomena in 2 pictures.

A significantly higher percentage of patients with PTCS depicted diplopia, such as crossed eyes or double images, compared with patients with migraine (28.6% vs 0.6%, respectively; P <.000001).

Participants in this study had been evaluated by a physician prior to entering the study and may have been asked diagnosis-specific leading questions, which could have influenced their headache depictions. It’s also possible that the patients had received a diagnosis prior to enrollment as some patients wrote the terms “pseudotumor” or “migraine” in their images.

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The investigators suggest using drawings in a comprehensive diagnostic assessment of diplopia in pediatric patients as these patients may find “drawing their headache is an enjoyable and empowering experience, offering an opportunity to express their symptoms nonverbally and offering the clinician considerable insight into the patient’s emotional experience of headache symptoms.”


Lee EB, Edelman FS, Stafstrom CE. Evidence of diplopia in children’s headache drawings helps to differentiate pseudotumor cerebri from migraine. Pediatr Neurol. 2018;79:40-44.