Stafstrom CE, Rostasy K, Minister A. The usefulness of children's drawings in the diagnosis of headache.

Stafstrom CE, Rostasy K, Minister A. The usefulness of children's drawings in the diagnosis of headache. Pediatrics 2002;109:460–72. The authors conducted an entertaining study designed to determine whether drawings can aid in the differential diagnosis of headaches in children. Before any formal history was obtained, 226 children (aged 4 to 19 years, mean 11.4 years) with a chief complaint of headache were asked: "Please draw a picture of yourself having a headache. Where is the pain? Are there any other changes that come with your headache that you can show me in your picture?" No leading questions were asked. With a pencil and a single piece of paper for each headache type, all children complied with the request. Two pediatric neurologists, who were blinded to the clinical history, analyzed the drawings independently. Pictures were graded as either migrainous or nonmigrainous. Specific features of the drawings that were considered to represent migraine included depiction of severe pain with a pounding/hammering quality, nausea or vomiting, sensitivity to light and/or sound, desire to sleep, headache exacerbation by exercise or movement, or clear-cut unilaterality. Overall, 57.5% of the children were given a clinical diagnosis of migraine or mixed headache with a prominent migraine component. The remaining headaches were diagnosed as nonmigraine for a wide variety of causes. Interrater agreement was excellent, with a Kappa score of 0.92. The drawings had a sensitivity of 93% and a specificity of 83% when compared with the "gold standard" of the clinical diagnosis. The results were then stratified into three groups according to age. Surprisingly, there were fewer false positive and false negative results in the youngest age group. This study adds to the growing literature on migraine art. The illustrative examples in this paper must be seen to be fully appreciated. Asking children to draw their headache is a simple and accurate adjunctive aid for headache differential diagnosis in the clinical setting. Drawings can be completed in the waiting room, with instructions given by a nurse or receptionist. For most children, this becomes an enjoyable exercise that also serves as a useful clinical adjunct.