Headache Medicine 2021, 12(2) p-ISSN 2178-7468, e-ISSN 2763-6178

134

ASAA

DOI: 10.48208/HeadacheMed.2021.24

Headache Medicine

Original

Pediatric patients at a high risk of headache of ocular origin: the

HAMS Score (Hyperopia, Astigmatism, Myopia, and Strabismus)

Paulo de Tasso Valença Veloso de Siqueira

, Luciana Patrízia Alves de Andrade Valença

Juliana Ramos de Andrade

, Marcelo Moraes Valença

1,2

Universidade Federal de Pernambuco, Recife, Brazil

Unimed Recife, Recife, Brazil

Abstract

Background

Pediatric patients identied at increased risk for headache due to ocular refractive errors were

evaluated to produce a diagnostic tool called the HAMS score that will help establish the

likelihood of headache due to refractive errors.

Methods

Data on the ocular diagnosis and headache complaints of 726 pediatric patients of both sexes

were obtained from the medical records of an ophthalmological service in Brazil (Hospital de

Olhos Santa Luzia). Age, use of glasses, and ocular diagnosis were also considered to create

an index based on the number of ocular diagnoses in a given individual (HAMS score) to

verify their association with the incidence of headache. Once the database was nalized, it

was then analyzed to identify the variables capable of predicting the occurrence of headaches,

following which a prole of those at the highest risk was produced by comparison.

Results

Only the ocular diagnosis was signicantly associated with headache as a function of sex, age,

use of glasses, farsightedness, astigmatism, myopia, and strabismus, indicating the relative

impact of each ocular diagnosis on the probability of headache. According to the HAMS sco-

re, strabismus is more likely to have headache (5.21), followed by hyperopia (3.10), myopia

(2.67), and, nally, astigmatism (1.86). The ndings showed that the presence or absence of

refraction errors and strabismus is predictive of the occurrence of headache, particularly in a

small group of patients (6.2%) where the probability of headache was 57.8%. Such patients

were characterized by being younger, having a combination of strabismus, hyperopia, and

astigmatism, and already be using corrective lenses.

Conclusion

The index based on the most common ocular diagnoses (HAMS score) is effective, and it has

practical application in identifying children and adolescent patients with a greater or lesser

propensity for headaches of ophthalmic origin.

Marcelo Moraes Valença

mmvalenca@yahoo.com.br

Edited by:

Mário Fernades Prieto Peres

Keywords:

Headache

Ocular diagnosis

Pediatric patients

Refractive Errors

Strabismus

Myopia

Received June 8, 2021

Accepted September 11, 2021

135

ASAA

Siqueira PTVV, Valença LPAA, Andrade JR, Valença MM

Pediatric patients at a high risk or headache of ocular origin: the HAMS Score (Hyperopia, Astigmatism, Myopia, and Strabismus)

Introduction

or more than one century, the relationship between eye

and headache attacks has been studied.

1-19

Headache

episodes of ocular origin can occur as a local event trig-

gering a primary headache attack such as migraine.

The

mechanisms involved in such cases are any affections that

interfere with the correct functioning of the optical system,

which might lead to a headache. This includes refraction

errors (myopia, astigmatism, hyperopia), heterotropia (stra-

bismus), inammatory disease (keratitis, uveitis, scleritis),

infections (corneal ulcers, conjunctivitis, endophthalmitis),

and glaucoma (closed-angle, neovascular), as well as orbital

pathologies (cellulitis, orbital pseudotumors, tendinitis), and

any affection of the fth cranial pair.

21-26

Among children, the leading cause of headaches are

migraine and tension-type headache,

27-29

though they are

considered to be fairly rare, occurring in 2-5% of those below

the age of 15 years, with the peak incidence occurring

between the ages of 10 and 15.

Approximately 4.3%

of the children and adolescents experience headaches

by the age of two or three, with a gradual increase until

they reach school age.

In adolescents, the gures tend to

surpass 50%.

Below the age of 10, primary headaches are generally

more prevalent in males than in females,

but the female

sex usually predominates during adolescence.

There

is also an association with age itself, for complaints of

headaches tend to increase as the children get older.

32,35,36

However, the role of ocular causes in headache medicine,

particularly in children and adolescents, is still controversial.

Parents and caretakers of children with headaches frequently

suspect the origin to be refraction errors.

37,38

However,

corrective lenses usually do not change the characteristics

or course of the headaches even when a refraction error

is effectively diagnosed.

For this reason, when a child

experiences headaches, one of the most commonly

consulted specialists is the ophthalmologist.

38,40-44

The

ofcial word of the International Headache Society is

that uncorrected refraction errors and heterotropia may

cause headaches,

but their importance is enormously

overestimated. Regarding heterotropia, it is read in the

ICHD-3 that “there are a number of supportive cases

for A11.3.5 Headache attributed to heterophoria or

heterotropia but otherwise little evidence for this cause of

headache. It has therefore been moved to the Appendix

pending more formal study.”

A case series of pediatric patients seen at an ophthalmology

service with complaints of headache were analyzed

with the aim of producing a useful diagnostic tool called

the HAMS Heavy Score. This tool will help establish

the likelihood of headache due to refractive errors and

heterotropy and provides a checklist of attributes that may

help identify pediatric patients at increased risk for ocular

headache.

Methods

Sample

The present study included data from 726 patients, between

3 months and 19 years, brought to an ophthalmological

service (Hospital de Olhos Santa Luzia) in Recife,

Pernambuco, Brazil, between January and October of

2011. The independent variables age, sex, use of glasses,

headache complaint and ocular diagnosis, to create an

index based on the number of diagnoses of hyperopia,

astigmatism, myopia and strabismus on a given individual

(HAMS Score) were considered to verify their association

with the incidence of headaches. Table 1 shows the

distribution of age and sex for the series obtained.

Table 1. Sex and age of the patients

Age (years)

Sex

Total

Male Female

n % n % n %

0 to 4 105 31.0 122 31.5 227 31.3

5 to 8 106 31.3 120 31.0 226 31.1

9 to 12 114 33.6 121 31.3 235 32.4

13 to 19 14 4.1 24 6.2 38 5.2

Total 339 100 387 100 726 100

There were no differences between the two sexes regarding

age (z=0.061 and p=.95 in the Mann-Whitney U test).

Of the total patients, 46.4% had hyperopia, 34.6%

astigmatism, 13.2% strabismus, and 5.8% myopia, with

39.0% presenting other diagnoses. There was a signicant

variety; however, none surpassed 2.8% of the sample (i.e.,

all had only 20 cases or fewer). Only the diagnoses of

refraction errors or heterotropia were considered frequent

enough for statistical evaluations. 25.2% of the patients

wore glasses, and 18.1% complained of headaches.

Analysis

Logistic regressions were used to measure the explanatory

136

ASAA

Siqueira PTVV, Valença LPAA, Andrade JR, Valença MM

Pediatric patients at a high risk or headache of ocular origin: the HAMS Score (Hyperopia, Astigmatism, Myopia, and Strabismus)

power of the independent variables in estimating the

probability of headache while controlling for covariance

effects. The rst group of independent variables considered

was: age, sex, use of glasses, headache complaint, and

ocular diagnosis; the other group considering the variables:

hyperopia, astigmatism, myopia, and strabismus. An

index was created based on the regression results that

differentiates those with a greater or lesser chance of

headache based on the ocular diagnosis.

Results

Only the ocular diagnosis gave a signicant association

with headache as a function of sex, age, use of glasses,

hyperopia, astigmatism, myopia, and strabismus (Table 2).

Sex, age, and the use of glasses, on the other hand, did not

emerge as having such an association when one controlled

for the existence of refraction errors and strabismus.

Table 2. Logistic regression of headache complain as a function of sex, age,

use of glasses, hyperopia, astigmatism, myopia, and strabismus

Method: Quasi-Newton

Chi²=93.442 p<.01

Sensitivity = 15.3%; Specicity = 97.3%

Positive Predictive Value = 55.6%; Negative Predictive Value = 83.9%

Variable Beta

Odds-Ratio

Wald chi-square (p)

Female sex 0.35 1.42 0.10

Age 0.02 1.07 0.87

Use of glasses -0.45 0.64 0.11

Myopia 1.25 3.50 0.01

Hyperopia 1.18 3.26 <0.01

Astigmatism 0.79 2.20 <0.01

Strabismus 1.78 5.93 <0.01

Constant 2.70 <.01

The low sensitivity observed considering only hyperopia,

astigmatism, myopia, and strabismus as independent

variables can be explained by: (a) the relatively low

incidence of headache (18.0%) in the sample, and (b) the

generic and unspecic nature of headaches as a symptom.

Regardless of this, these ndings demonstrate the existence

of explanatory power of the ocular diagnosis when it

comes to headaches (Table 3).

The odds ratios found for each of the diagnoses indicate

the relative impact of each ocular diagnosis upon the

probability of headache. Therefore, it may be said

that strabismus has the most signicant effect (5.21),

followed by hyperopia (3.10), myopia (2.67), and, lastly,

astigmatism (1.86).

Table 3. Logistic regression of headache complain as a function of hyper-

opia, astigmatism, myopia, and strabismus

Method: Quasi-Newton

Chi²= 88.232 p<.01

Sensitivity = 12.2%; Specicity = 97.5%

Positive Predictive Value = 51.6%; Negative Predictive Value = 83.5%

Variable Beta

Odds-Ratio

Wald chi-square (p)

Myopia 0.98 2.67 0.03

Hyperopia 1.13 3.10 <0.01

Astigmatism 0.62 1.86 0.01

Strabismus 1.65 5.21 <0.01

Constant 2.79 <0.01

Cumulative Impact of Refraction Errors and Strabismus

The number of diagnoses of hyperopia, astigmatism,

myopia, or strabismus on a given individual (HAMS Score)

is a measure of the number of combined ocular disorders

one may have. Roughly, 39.0% have a score of zero,

26.4% a score of one, 30.2% a score of two, and only

4.4% a score of three.

The HAMS Score can be used to determine the cumulative

effect of refraction errors and heterotropia on the probability

of headache, as shown in Figure 1.

Figure 1. The frequency of children with headache in relation to

the HAMS (Hyperopia, Astigmatism, Myopia, and Strabismus)

Score.

One can see that there is a clear trend towards an increase

in the incidence of headache as the HAMS Score gets

higher, with the probability of headache being only 3.5%

when the score is zero but climbing as high as 50.0% when

the score is three. This makes such a score a somewhat

valuable tool.

137

ASAA

Siqueira PTVV, Valença LPAA, Andrade JR, Valença MM

Pediatric patients at a high risk or headache of ocular origin: the HAMS Score (Hyperopia, Astigmatism, Myopia, and Strabismus)

However, despite its usefulness and simplicity, the HAMS

Score has the fundamental aw of considering all four

ocular diagnoses (i.e., hyperopia, astigmatism, myopia,

and strabismus) as having equal weight. At the same time,

the analysis in Table 4 clearly shows that this is not the

case. One way to correct this is to create a version of the

score where the weight of each component is given by

the odds-ratio obtained in the logit regression so that a

Weighed HAMS Score can be produced according to the

following formula:

Weighed HAMS Score=5.21 *Strabism.+3.10+Hyperop.

+2.67*Myop.+1.86*Astigm

For the sample studied, the distribution of the Weighed

HAMS Score was such that 39.0% had a value of zero,

20.0% a value between 0.1 and 4.1, 34.9% a value

between 4.1 and 8.0, and 6.2% a value of 8.1 or higher.

Figure 2 shows the relationship between the Weighed

HAMS Score and the incidence of headache in the present

study.

Figure 2. The frequency of children with headache in relation to the

HAMS (Hyperopia, Astigmatism, Myopia, and Strabismus) Score.

In Figure 2, there is a clear trend towards an increase in

the frequency of headache as the Weighed HAMS Score

gets higher. The probability of headache was only 3.5%

when the score was zero, but it became as high as 57.8%

when the score was 8.1 or more. The Weighed HAMS

Score has the advantage of producing a more signicant

differentiation between the probabilities of highest and

lowest levels (57.8% versus 3.5%, a ratio of 16.51) than

the one obtained by the simple HAMS Score (50.0% versus

3.5%, a ratio of 9.43). Furthermore, the margin of error in

the estimation of the probability of the highest level of the

score was smaller in the case of the Weighed HAMS Score

(25.3%) than in the simple HAMS Score (35.2%).

Profile of pediatric patients with a high risk for

headache of ocular origins

Table 4 compares the patients with a score on the Weighed

HAMS Scale that is equal to or greater than 8.1 with those

with a score below 8.1, with regards to sex, age range,

use of glasses, refractory errors, and strabismus. The

patients with a higher Weighed HAMS Score were much

more prone to experiencing headaches (57.8% versus

15.4%). As to their other traits, statistical differences were

found regarding:

Table 4. Comparison between patients with a higher (>8.1) and lower (<8.1)

Weighed HAMS (Hyperopia, Astigmatism, Myopia, and Strabismus) Score

Variables

Weighed HAMS Score

Canonical

test (p)

≥ 8.1 (n=45)

<8.1 (n=681)

Sex

Male 44.4% 46.8%

0.76

Female 55.6% 53.2%

Age

(years)

0-4 42.2% 30.5% 0.10

4-8 35.6% 30.8% 0.51

8-12 15.6% 33.5% 0.01

>12 6.7% 5.1% 0.66

Refraction

Errors

Hyperopia 93.3% 43.3% <0.01

Astigmatism 68.9% 32.3% <0.01

Myopia 6.7% 5.7% 0.79

Strabismus 100% 7.5 % <0.01

Use Glasses 80.0% 21.6% <0.01

Headache 57.8% 15.4% <0.01

. Age: Among those with higher Weighed HAMS Score,

there were fewer patients in the 8 to 12-year-old bracket

and, marginally, more patients in the 0 to 4-year-old range

(adjusted Z=-2.024 and p=.04 on the Mann-Whitney U

test for the difference in age as a whole, with the higher

Weighed HAMS Score group being younger);

. Refraction Errors: The group with higher Weighed HAMS

Score had a much greater proportion of patients with

hyperopia (93.3% versus 43.3%) and astigmatism (68.9%

versus 32.3%);

. Strabismus: All patients in the higher Weighed HAMS

Score group (100%) had strabismus, whereas there were

only 7.5% of the lower Weighed HAMS Score group with

this condition;

. Use of Glasses: About 80.0% of the high Weighed

HAMS Score group wore glasses, while only 21.6% of the

others did the same.

138

ASAA

Siqueira PTVV, Valença LPAA, Andrade JR, Valença MM

Pediatric patients at a high risk or headache of ocular origin: the HAMS Score (Hyperopia, Astigmatism, Myopia, and Strabismus)

Interestingly, though 100% of the high WBS group had

strabismus, such group represents only 46.9% (45 out of

96) of all the patients with that condition.

Discussion

Age, Sex, Glasses, and Headache

Once one controlled covariance with other variables,

particularly refraction errors and strabismus, there was no

association between sex, age, glasses, and headache.

This suggests that an increase in the prevalence of

headaches in the female sex and older children might

not be a consequence of sex and age per se, but rather

the association between such things and other factors

(covariance), particularly with ocular diagnoses.

44-46

Ocular Diagnoses and Headache

Logistic regression of the incidence of headache as a

function of the ocular diagnosis showed that strabismus

was the strongest predictor of headaches (odds-ratio of

5.21), followed by hyperopia (odds-ratio of 3.10) and

myopia (odds-ratio of 2.67), with astigmatism having the

smallest impact (odds-ratio 1.86). This may be due to the

specic mechanisms involved in such affections, such as

the practical impact on vision and eyestrain.

It is important to note that only one-tenth of all the patients

with headache at the ophthalmological service can be

explained by ocular diagnoses, which is consistent with the

existence of a myriad of causes of headache, and also with

the fact that headaches in children and adolescents have a

relatively low.

39,44

However, such a percentage of patients

with headache that can be predicted by ocular diagnoses

is large enough to be relevant in clinical practice, and,

as it will be discussed in the following subsection, there

is a cumulative effect that, under certain conditions,

are associated to a probability of more than 50% of a

headache occurs.

HAMS and the Cumulative Impact of Ocular Diagnoses

The accumulation of HAMS diagnoses was shown to be

associated with a fairly dramatic increase in the incidence

of headache in this series (from 3.5% to 50.0%, a relative

risk of 9.43), especially when one ponders the individual

impact of each specic diagnosis (from 3.5% to 57.8%,

a relative risk of 16.51).

39,46

Such a nding suggests

that ocular problems, particularly refraction errors and

strabismus, have a relevant impact on the occurrence of

headache among children and adolescents, especially

when such issues accumulate in the same patient. In the

most extreme cases (Weighed HAMS Score >8.1), which

encompass 6.2% of the patients studied, the probability

of headache can be as high as 57.8%, meaning that, for

them, it is more likely that a headache will occur than that

it will not.

Profile of High-Risk Pediatric Patients

Based on the Weighed HAMS Score, the present study results

showed that pediatric patients at high risk for headaches

of ocular origins tend to be younger, with a greater

prevalence of those in early childhood than those above

four. In terms of ocular health, all of them had strabismus

(100%), almost all had hyperopia (93.3%), and more

than two-thirds of them had astigmatism (68.9%), which is

why the vast majority wore glasses (80.0%). Considering

these ndings, it would appear that younger patients with

strabismus plus hyperopia and astigmatism, even though

most of them already use corrective lenses, should be

considered at high risk for suffering from headaches of

ocular causes; thus requiring special attention on behalf of

the ophthalmologist regarding the investigation of causes

and planning of treatment, including the possibility of a

consultation with a neurologist.

Conclusion

Is possible and relatively easy to construct an index

based on the most common ocular diagnoses (Weighed

HAMS Score), which is of practical application in

identifying patients with a greater or lower propensity

towards headaches of an ophthalmological origin. Ocular

diagnoses, particularly hyperopia, astigmatism, myopia,

and strabismus, seem to play a relevant cumulative role in

the occurrence of headaches in children and adolescents,

especially in the small number of patients where such

ocular affections are combined to a signicant degree. In

this particular subgroup, it is more likely that headache

episodes will occur.

The group of patients with a very high propensity for

headache episodes is characterized by being younger,

having a combination of strabismus, hyperopia,

astigmatism, and already using corrective lenses. The risk is

so signicant that it should be presumed that these patients

will have headaches. The accompanying measures of such

an assumption (further investigation, treatment planning,

consulting with other experts) appear to be taken by

negligence.

139

ASAA

Siqueira PTVV, Valença LPAA, Andrade JR, Valença MM

Pediatric patients at a high risk or headache of ocular origin: the HAMS Score (Hyperopia, Astigmatism, Myopia, and Strabismus)

Future studies on the subject of the relationship between

ocular diagnoses and headache should include a

substantially larger series of patients than the present to

allow for the evaluation of the impacts of ophthalmological

diseases other than HAMS, as well as a more detailed

description of the headache characteristics (intensity,

location, duration) and the ocular health, along with data

on treatments and outcomes, to provide a complete view of

the phenomena observed, thereby allowing one to obtain

ndings capable of shedding light upon the possible

mechanisms involved, as well as producing more accurate

diagnostic and prognostic models, as well as proles.

Conflict of interest: the authors declare no conict of

interest.

Funding: There was no funding for this research.

Author contributions: PTVVS, collected the data and paper

draft; LPAAV, JRA and MMV carried out the review of the

nal version.

Paulo de Tasso Valença Veloso de Siqueira

https://orcid.org/0000-0002-9570-6924

Luciana Patrízia Alves de Andrade-Valença

https://orcid.org/0000-0002-3487-0325

Juliana Ramos de Andrade

https://orcid.org/0000-0002-5445-8872

Marcelo Moraes Valença

https://orcid.org/0000-0003-0678-3782

References

1. Chilaris GA. Headache of ocular origin.

Gaz Med Fr

1954;61(10):685-686

2. Gifford ES, Jr. Headache of ocular origin.

1954;9(4):55-57

3. Wyrick R. Diagnosis of ocular headache.

J Okla State

Med Assoc

1953;46(5):114-116

4. Dosal AF and Del Pinal JL. Headache of ocular origin.

Clin Lab

1952;54(321):424-433

5. Ehlers H. Ocular headache.

Manedsskr Prakt

Laegegern

1951;29(3):108-114

6. Ruedemann AD. Headache and head pain of ocular

origin.

J Am Med Assoc

1950;144(7):517-519

Doi:10.1001/jama.1950.02920070005002

7. Baker IS. Ocular headache.

Optician

1947;113(2926):267; passim

8. Baker IS. Ocular headache.

Optician

1947;113(2923):191; passim

9. Cooper EL. Ocular causes of headache.

J Mich State

Med Soc

1946;45:485-488

10. Stewart DS. Ocular Headache.

Br Med J

1937;2(3992):59-60 Doi:10.1136/bmj.2.3992.59

11. Fergus F. Headache and Ocular Treatment.

Glasgow

Med J

1908;70(5):321-338

12. Hinshelwood J. Some Observations on Ocular and

Other Forms of Chronic Headache.

Glasgow Med J

1904;61(1):7-19

13. Hinshelwood J. Ocular Headache.

Glasgow Med J

1900;54(5):335-343

14. Mittendorf WF. Four thousand cases of Ocular

Headache and the different states of refraction

connected therewith.

Trans Am Ophthalmol Soc

1895;7:339-347

15. Cross FR. Asthenopia and Ocular Headache. Bristol

Med Chir J (1883) 1893;11(40):73-84

16. Higgens C. Ocular Headache.

Br Med

1883;1(1171):1115 Doi:10.1136/

bmj.1.1171.1115

17. Chamlin M. Headache of ocular origin.

Int J Neurol

1962;3:360-367

18. Jampel RS. Ocular factors in headache.

Headache

1965;5(3):82-86 Doi:10.1111/j.1526-4610.1965.

hed0503082.x

19. Reddy SC. Ocular causes of headache and its

management.

J Indian Med Assoc

1980;75(2):34-36

20. MacCumber MW, Jaffe GJ and McCuen BW.

Treatment of Migraine Headache After Ocular Surgery

With Intravenous Metoclopramide Hydrochloride.

J Ophthalmol

1996;121(1):96-97 Doi:10.1016/

S0002-9394(14)70542-2

21. Morell M, Clement E, Bernad MJ, Berbegal P and

Soler S. A new type of headache of ocular origin:

ophthalmotonic headache. Diagnosis and treatment.

Rev Neurol

1997;25(146):1557-1560

22. Daroff RB. Ocular causes of headache.

Headache

1998; 38(9): 661 Doi: 10.1046/j.1526-

4610.1998.3809661.x

23. Ringeisen AL, Harrison AR and Lee MS. Ocular and

orbital pain for the headache specialist.

Curr Neurol

Neurosci Rep

2011;11(2):156-163 Doi:10.1007/

s11910-010-0167-6

24. Verdure P, Le Moigne O, Massardier EG, Vanhulle

C, Tollard E and Maltête D. Migraine-like headache

and ocular malformations may herald Moyamoya

syndrome.

Rev Neurol (Paris)

2012;168(5):460-461

Doi:10.1016/j.neurol.2011.09.011

25. Park T and Choi G. Unilateral fronto-temporal

headache with ocular pain caused by lens subluxation

due to spontaneous zonulysis.

Clin Exp Emergency

Med

2015;2(2):133-136 Doi:10.15441/

ceem.15.031

26. Hackett A, Stuart J, Blessing N and Borden N. Headache

with Aura: A case report of ocular melanoma.

Am J

140

ASAA

Siqueira PTVV, Valença LPAA, Andrade JR, Valença MM

Pediatric patients at a high risk or headache of ocular origin: the HAMS Score (Hyperopia, Astigmatism, Myopia, and Strabismus)

Emerg Med

2018;36(11):2135.e2137-2135.e2138

Doi:10.1016/j.ajem.2018.08.047

27. Arruda MA, Arruda R, Guidetti V and Bigal ME.

Psychosocial adjustment of children with migraine and

tension-type headache - a nationwide study.

Headache

2015;55 Suppl 1:39-50 Doi:10.1111/head.12510

28. Arruda MA, Guidetti V, Galli F, Albuquerque RC and

Bigal ME. Migraine, tension-type headache, and

attention-deficit/hyperactivity disorder in childhood: a

population-based study.

Postgrad Med

2010;122(5):18-

26 Doi:10.3810/pgm.2010.09.2197

29. Arruda MA, Guidetti V, Galli F, Albuquerque RC

and Bigal ME. Frequency of headaches in children

is influenced by headache status in the mother.

Headache

2010;50(6):973-980 Doi:10.1111/

j.1526-4610.2010.01677.x

30. Dias MJM. Cefaleias na criança.

Pediatria

1983;5(5):295-299

31. Gorayeb MAM and Gorayeb RJAdn-p. Association

between headache and anxiety disorders indicators

in a school sample from Ribeirao Preto, Brazil.

Arq

Neuropsiquiatr

2002;60(3B):764-768 Doi:10.1590/

S0004-282X2002000500016

32. Puccini RF and Bresolin AMB. Recurrent pain in

children and adolescents.

J Pediatria

2003;79:S65-S76

Doi:10.2223/jped.1001

33. Oster J. Recurrent abdominal pain, headache and

limb pains in children and adolescents.

Pediatrics

1972;50(3):429-436

34. Mortimer MJ, Kay J, Gawkrodger DJ, Jaron A and

Barker DC. The prevalence of headache and migraine

in atopic children: an epidemiological study in

general practice.

Headache

1993;33(8):427-431

Doi:10.1111/j.1526-4610.1993.hed3308427.x

35. Gherpelli J. Treatment of headaches.

J Pediatr

2002;78(Suppl 1):S3-8 Doi:10.2223/jped.844

36. Sillanpää M. Changes in the prevalence of

migraine and other headaches during the first

seven school years.

Headache

1983;23(1):15-19

Doi:10.1111/j.1526-4610.1983.hed2301015.x

37. Mehboob MA, Nisar H and Khan M. Ametropia

in children with headache.

Pak J Med Sci

2019;35(3):701-704 Doi:10.12669/pjms.35.3.268

38. Harle DE, Evans BJ and science v. The correlation

between migraine headache and refractive errors.

J Optometry

2006;83(2):82-87 Doi:10.1097/01.

opx.0000200680.95968.3e

39. Roth Z, Pandolfo KR, Simon J and Zobal-Ratner J.

Headache and refractive errors in children.

J Pediatr

Ophthalmol Strabismus

2014;51(3):177-179

Doi:10.3928/01913913-20140429-02

40. Hendricks TJ, J DEB, van Der Horst FG, Hendrikse

F and Knottnerus JA. Relationship between habitual

refractive errors and headache complaints in

schoolchildren.

Optom Vis Sci

2007;84(2):137-143

Doi:10.1097/OPX.0b013e318031b649

41. Dotan G, Stolovitch C, Moisseiev E, Cohen S and

Kesler A. Uncorrected amteropia among children

hospitalized for headache evaluation: a clinical

descriptive study.

BMC Pediatr

2014;14:241

Doi:10.1186/1471-2431-14-241

42. Headache Classification Committee of the

International Headache Society (IHS) The

International Classification of Headache Disorders,

3rd edition.

Cephalalgia

2018;38(1):1-211

Doi:10.1177/0333102417738202

43. Jeddi A, Ben Hadj Alouane W, Hammoud M,

Malouch N, Zghal I, Ayed S and Zouari B. Full

optical correction after cycloplegia in headache.

J Fr

Ophtalmol

2002;25(3):270-273

44. Akinci A, Güven A, Degerliyurt A, Kibar E, Mutlu

M and Citirik M. The correlation between headache

and refractive errors.

J aapos

2008;12(3):290-293

Doi:10.1016/j.jaapos.2007.11.018

45. McKendrick AM and Nguyen BN. The eye in migraine:

a review of retinal imaging findings in migraine.

Clin

Exp Optom

2021;1-8 Doi:10.1080/08164622.202

1.1971045

46. Importance of eye disease in headache.

Emerg Nurse

1996;3(4):27 Doi:10.7748/en.3.4.27.s14