Children's Drawings Help Physicians Diagnose Headache

04 April 2002
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Before taking any history, 226 children were asked to draw a picture to show themselves having a headache: the location of the pain, what the pain feels like, and any other changes or symptoms that come before or during a headache. Without looking at the drawings, Dr. Stafstrom then completed the clinical evaluation and diagnosed the headache type. Of the 226 children, 57.5% were diagnosed as having migraine or mixed headache with a prominent migraine component, and the remaining 96 children had nonmigraine headaches.

Later, the drawings were analyzed independently by two pediatric eurologists who were blind to the clinical history. They were asked to evaluate each drawing and decide, based on their own clinical experience, whether the pictures were consistent with migraine or nonmigraine headaches. The drawings with migraine features corresponded to the clinical diagnosis in 87% of cases, whereas the drawings without migraine features matched in 91% of cases.

Approximately 17% of children with nonmigraine headaches drew pictures showing severe or pounding pain. Children suffering from migraine typically drew pictures that showed objects hitting the head, such as hammers, baseball bats, or rocks. Pictures depicting dizziness, sadness, or crying were equally divided among patients. Drawings showing a tight band around the head characterized the squeezing pain associated with tension-type headaches; only 1 of 9 children who illustrated this type of pain had migraine.

Dr. Stafstrom says that while there is a wide variability in the quality of drawings across ages and between children of the same age the children, unlike adults, are not shy about expressing themselves artistically. Dr. Stafstrom notes that while child psychiatrists and psychologists often use drawings to analyze children's feelings, they have been surprisingly underused in headache diagnosis. He encourages clinicians to adopt this tool, describing it as a "simple, inexpensive, and accurate method as a powerful adjunctive aid for headache differential diagnosis in the clinical setting". "For the vast majority of children", he says, "headache drawing is an enjoyable exercise that allows the opportunity to express their symptoms and feelings and may afford greater insight into their pain."

Stafstrom CE, et al. The Usefulness of children's drawings in the diagnosis of headache. Pediatrics 2002; 109(3): 460-472.

These drawings all show images of pounding or throbbing pain. A: drawn by a 9-year-old boy, shows pain being inflicted by a hammer and chisel. The chisel has made indents in his skull. B: 14-year-old girl and shows a baseball bat pounding her head. In C: 15-year-old boy demonstrates pain from a hammer, complete with accompanying expletives. D: 12-year-old girl and shows "throbbing midfrontal pain" from a reflex hammer. E: 10-year-old boy showing pounding pain "like a drum set in my brain", and F: 14-year-old boy depicting a small figure inside his brain hitting him with a hammer. All of these drawings were rated as migraine, both clinically and by drawing.

These drawings are examples of the visual disturbances accompanying migraine headache. A: 16-year-old girl depicts sensitivity to light and sound, and pain in both temples. B: 12-year-old girl shows a light bulb in the upper left demonstrating visual aura. She also shows head pain and stomach nausea. C: 9-year-old-girl draws visual aura. D: 10-year-old girl also shows visual aura - spots and/or flashing lights. E: 14-year-old boy draws his left visual field showing a rim of blurriness with objects in the center shown clearly. F: 14-year-old boy shows a normal visual field before the headache begins (left side) followed by disturbed vision across his left visual field from the center toward the outside over several minutes. All of these drawings were rated as migraine, both clinically and by drawing.


Drawings courtesy of Dr. Carl E. Stafstrom and Pediatrics.