Simple, black-and-white drawings done on a sheet of unlined paper seem to be an effective way to differentiate between migraine and non-migraine headaches in children.

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Drawings complement traditional diagnosis

In a sample of 226 children, such drawings were about 90 percent accurate in predicting the correct diagnosis, according to a new study published in the March issue of Pediatrics.

The researchers caution, however, that artwork should not replace traditional diagnostic methods.

"The drawings are an adjunct to go along with clinical judgment. They contribute in a supportive way," says Dr Carl Stafstrom, lead author and an associate professor of neurology and paediatrics at the University of Wisconsin. "I would hate to put forth the idea that this makes it or breaks it, but it has been very valuable, especially when kids draw two or three different headache types. That helps me to figure out which ones are severe and need treatment."

"It's a very nice approach," says Dr Walter Molofsky, associate chairman of the department of neurology and director of the paediatric headache service at Beth Israel Medical Centre in New York City. "Having said this, you're not going to make a diagnosis of migraine on the basis of a picture. It's not a substitute for a more comprehensive history, but I think it's a very nice way of incorporating this kind of information from the child into what you get."

Diagnosis of childhood migraines difficult

Headaches are a common complaint during childhood, with as many as two-thirds of children complaining of headaches severe enough to necessitate a visit to a doctor. The prevalence of migraines in childhood is thought to be high - between two percent and 11 percent.

Diagnosing migraines, especially in children, can be problematic. Because there are no imaging or blood tests, diagnoses usually rely on subjective interpretations.

Most physicians agree migraine episodes have at least two additional symptoms, including aura, nausea, vomiting or throbbing. These symptoms can change over time, and children tend to have shorter episodes, are less likely to have a visual aura, and are more likely to have nausea, vomiting and flushing or pallor.

Drawing is widely used by psychiatrists and psychologists to probe children's hidden feelings, and there is a substantial body of artwork by adults with migraines. This technique had not previously been used with children suffering from headaches.

The study

In this study, the researchers asked 226 children between the ages of four and 19 who complained of headaches to draw a picture of themselves having a headache.

The children, who were supplied with a blank, unlined sheet of paper and a pencil with an eraser, were also asked, "Where is your pain? What does your pain feel like? Are there any other changes of symptoms that came before or during your headache that you can show me in a picture?"

After the drawings were completed, the children were examined and diagnosed by a neurologist. The drawings were analysed independently by two paediatric neurologists who had not met the children or their parents, and knew nothing of the children's clinical histories.

A total of 139 drawings were categorised as migraine, while a total of 130 children were diagnosed as having a migraine or mixed headache.

The drawings varied but, generally, the "migraine drawings" included depictions of pounding or severe pain, as well as the gastrointestinal symptoms and visual phenomena.

Child can describe pain in their own way

Although there was occasional resistance, no child refused the request.

"When I first suggest this to a child, they look at me weirdly and then all of a sudden they start," Stafstrom says. "You're touching something deep down."

This speaks to another benefit of the method: relationship-building.

"They've given children an opportunity to speak in a pictorial way - a way, with minimal direction, to get them to describe their feelings and what's going on with the headaches," Molofsky says. "It is also a respectful thing to do. It gives the children a voice in describing what's going on."

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