Headache is a frequent complaint during childhood and adolescence and may interfere with school attendance, concentration, social participation and quality of life. Its frequency increases with age, and epidemiological estimates vary substantially according to age, population, case definitions and ascertainment methods. A systematic review and meta-analysis of studies in children and adolescents estimated a pooled prevalence of approximately 62% for primary headache disorders, with migraine and tension-type headache among the most frequently reported subtypes [1]. These findings highlight the importance of a structured clinical assessment rather than assuming that headache in a child has a single or obvious cause. Children presenting to ophthalmology may have primary headache disorders, symptoms related to visual effort, refractive errors, oculo-motor abnormalities, or less commonly ocular disease indicating a potentially serious underlying condition. In a prospective study of 311 children attending an ophthalmology service in South India, Christopher et al. reported headache attributed to refractive error in 63.7%, migraine in 19.3% and tension-type headache in 7.1% [2]. By contrast, a North Indian study focused on children with primary headache reported migraine in 60% and tension-type headache in 28% [3]. A more recent ophthalmology-based study of 101 children found migraine to be the most common diagnosis (28.7%), followed by headache associated with inadequate refractive correction (23.7%) and tension-type headache (17.8%) [6]. Such variation is expected because referral setting, eligibility criteria, diagnostic definitions and the extent of ophthalmic and neurological assessment differ between studies. A large retrospective ophthalmology clinic series also found that newly identified ocular or potentially neurologically relevant findings occurred in a minority of children with headache, supporting the value of a comprehensive eye examination without presuming that every headache is ocular in origin [7]. The International Classification of Headache Disorders, third edition (ICHD-3), requires evidence supporting a causal relationship before headache is attributed to refractive error. Relevant features include a temporal relationship with the onset or worsening of the refractive error, aggravation during visual tasks at a distance where vision is impaired, improvement when the task stops, and improvement after appropriate correction; alternative headache diagnoses should also be considered [4]. This distinction is important because refractive errors may coexist with migraine or tension-type headache, and observational studies have not consistently shown that changing spectacle correction explains headache improvement [8]. The present study aimed to describe the demographic, headache-related and recorded ophthalmological characteristics of children aged 8–15 years presenting with headache to the ophthalmology outpatient department of Tripura Medical College and Dr BRAM Teaching Hospital, Agartala, Tripura.

Study design: A hospital-based cross-sectional observational study was planned. Study setting and period: The study setting was the Department of Ophthalmology, Tripura Medical College and Dr BRAM Teaching Hospital, Hapania, Agartala, Tripura, India. The study period was February 2024 to December 2025. Study population and sample size: The target population comprised children aged 8–15 years attending the ophthalmology outpatient department with a complaint of headache. The planned sample size was 100, using non-random convenience sampling. Inclusion criteria: Children aged 8–15 years presenting with headache to the Ophthalmology OPD, with informed consent from a parent or legal guardian and child assent where appropriate and required by the ethics committee. Exclusion criteria: Children presenting with headache attributable to fever, trauma or other infective causes such as meningitis, as well as headache due to dental conditions, were to be excluded. The source records should be checked to confirm that all retained participants met these criteria and that suspected sinusitis was handled consistently with the protocol. Headache classification and diagnostic criteria: Headache diagnoses were intended to be categorised using the International Classification of Headache Disorders. The study notes provided diagnostic descriptions for migraine, cluster headache, tension-type headache and headache associated with refractive error. For the final analysis, the current ICHD-3 criteria should be applied consistently [4]. Migraine assessment includes headache duration and characteristic pain features with associated symptoms; cluster headache requires recurrent severe unilateral orbital, supraorbital or temporal pain with characteristic ipsilateral autonomic features or restlessness; and tension-type headache requires the specified duration, pain characteristics and absence of prominent nausea/vomiting or combined photophobia and phonophobia. Headache attributed to refractive error should not be diagnosed solely because a refractive error is present. The history should document evidence of causation, such as temporal association with onset or worsening of refractive error, improvement after correction, aggravation during visual tasks at the affected viewing distance, or improvement after stopping the task, with alternative ICHD-3 diagnoses considered [4]. The final manuscript should clarify whether diagnoses were assigned prospectively by a clinician using full criteria or abstracted from existing records. Data collection procedure: After obtaining informed consent from the parent/guardian and assent where appropriate, demographic and socioeconomic information and a detailed headache history was collected using a predesigned proforma. The history included symptom duration, headache location and laterality, and associated symptoms including nausea, vomiting, photophobia, phonophobia, lacrimation, nasal congestion, rhinorrhea, sinus tenderness and temporomandibular joint tenderness. General and systemic examinations would be performed. The ophthalmological examination included visual acuity in each eye, refraction, intraocular pressure measurement and fundus examination. Ocular alignment and other examination findings were recorded where assessed. Sphere, cylinder and axis values was transcribed from the clinical examination. Statistical analysis: Categorical variables were summarized as counts and percentages; age was summarized using mean and standard deviation. Duration in months was summarized using the median and interquartile range. Diagnosis was dichotomized as refractive-error-associated headache versus all other diagnoses. Associations with sex and laterality were tested using Fisher’s exact test; age-band association was tested using Pearson’s chi-square test with categories ≤7, 8–10, 11–13 and 14–15 years to retain all records. Duration between diagnostic groups was compared using the Mann–Whitney U test. A two-sided p value <0.05 was considered statistically significant. Ethical considerations: Permission was obtained from the institutional Ethics Committee. Written and informed consent was obtained from the guardians.

Mean age was 12.40 ± 3.56 years with median of 13 years. Females comprised 65 (65%) and males 35 (35%). The most represented age band was 11–13 years (40 records, 40.0%) as shown in table 1. Table 1. Demographic profile of all supplied records (n=100) Characteristic N % ≤7 6 6.0 8–10 18 18.0 11–13 40 40.0 14–15 36 36.0 Female 65 65.0 Male 35 35.0 Distribution of headache diagnoses us as below (table 2): • Refractive error-associated headache: 55 (55.0%). • Migraine: 18 (18.0%). • Sinusitis: 10 (10.0%). • Tension-type headache: 7 (7.0%). • Asthenopia/Eye Strain: 5 (5.0%). • Other/Unspecified: 3 (3.0%). • Amblyopia: 1 (1.0%). • Cluster headache: 1 (1.0%). Table 2. Recorded final diagnoses among all supplied records (n=100) Diagnosis n % Refractive error-associated headache 55 55.0 Migraine 18 18.0 Sinusitis 10 10.0 Tension-type headache 7 7.0 Asthenopia/Eye Strain 5 5.0 Other/Unspecified 3 3.0 Amblyopia 1 1.0 Cluster headache 1 1.0 Total 100 100.0 Headache was recorded as bilateral in 54 (54%) and unilateral in 46 (46%). Median symptom duration was 2.00 months (interquartile range 0.50–5.25) as shown in table 3. Table 3. Associated symptoms and laterality among all supplied records (n=100) Variable Present n (%) Nausea 3 (3.0%) Vomiting 3 (3.0%) Photophobia 9 (9.0%) Phonophobia 8 (8.0%) Lacrimation 5 (5.0%) Nasal Congestion 11 (11.0%) Rhinorrhea 11 (11.0%) Sinus Tenderness 9 (9.0%) TMJ Tenderness 3 (3.0%) Bilateral headache 54 (54.0%) Unilateral headache 46 (46.0%) Note: Symptom indicators may co-occur; percentages do not sum to 100%. Percentages in this table use all 100 supplied records. Myopia, hypermetropia and astigmatism was reported among 70.91%, 18.18% and 10.91% of the subjects respectively (table 4). Table 4. Refractive-error flags among all supplied records (n=55) Finding N % Myopia 39 70.91 Hypermetropia 10 18.18 Astigmatism 06 10.91 For inferential analyses across all 100 records, refractive-error-associated headache was compared with all other recorded diagnoses. This comparison does not establish a causal relationship between refractive error and headache. No statistically significant association was detected between the recorded refractive-error-associated headache category and sex (p=0.834), age band (p=0.448), or laterality (p=0.688). Duration did not differ significantly between the refractive-error-associated headache group and the other-diagnosis group (median 2.00 vs 2.00 months; p=0.495) as shown in table 5. Table 5. Association of refractive-error-associated headache with demographic and clinical variables (n=100) Variable RE-associated headache n/N (%) Other diagnoses n/N (%) Test p value Female sex 35/65 (53.8%) 30/65 (46.2%) Fisher exact 0.834 Male sex 20/35 (57.1%) 15/35 (42.9%) Age ≤7 5/6 (83.3%) 1/6 (16.7%) Pearson chi-square (5 bands) 0.448 Age 8–10 11/18 (61.1%) 7/18 (38.9%) Age 11–13 19/40 (47.5%) 21/40 (52.5%) Age 14–15 20/36 (55.6%) 16/36 (44.4%) Bilateral headache 31/54 (57.4%) 23/54 (42.6%) Fisher exact 0.688 Unilateral headache 24/46 (52.2%) 22/46 (47.8%) Duration (months), median 2.00 2.00 Mann–Whitney U 0.495

Refractive-error-associated headache was the most frequently recorded diagnosis, followed by migraine and sinusitis. This distribution resembles the South Indian ophthalmology-based study by Christopher et al., in which 63.7% of children were classified as having headache attributed to refractive error, 19.3% had migraine and 7.1% had tension-type headache [2]. The North Indian retrospective study by Sinha et al. reported migraine in 60% and tension-type headache in 28% of children with primary headache [3]. This differs from the current distribution, which includes ophthalmology patients with recorded refractive error, asthenopia and sinusitis. Differences are expected when one study recruits children with primary headache and another recruits children presenting with headache to ophthalmology. Sinha et al. reported migraine and tension-type headache as the dominant diagnostic categories in a North Indian cohort [3]. In a recent study of 101 children undergoing a comprehensive ophthalmic assessment, Degrassi et al. reported migraine in 28.7%, headache associated with inadequate refractive error in 23.7%, tension-type headache in 17.8%, and strabismus-related headache in 16.8% [6]. These differences emphasise that observed diagnostic proportions are strongly influenced by the clinical setting, referral pathways, definitions used and whether the study starts with a general headache population, a primary-headache cohort or children referred to ophthalmology. The recorded refractive-error flags in the present dataset were myopia, hypermetropia and astigmatism; reported among 70.91%, 18.18% and 10.91% of the subjects respectively. In children, accommodation can influence non-cycloplegic measurements; therefore, the refraction to be performed under cycloplegia. The American Academy of Ophthalmology evidence review found that non-cycloplegic autorefraction may over-minus compared with cycloplegic measurements, reinforcing the need to describe the examination protocol when reporting paediatric refractive findings [9]. Importantly, the frequency of refractive error is not equivalent to the frequency of headache caused by refractive error. ICHD-3 specifies clinical evidence of causation, such as headache worsening in temporal relation to refractive change, worsening during visual tasks at the distance where vision is impaired, and improvement after stopping the task or correcting the refractive error [4]. In a study of 158 children evaluated for headache, most had normal or unchanged eye examinations; headache improvement was common both among children who received a new or modified spectacle prescription and among those who did not, with no statistically significant difference between groups [8]. This cautions against attributing headache to ametropia solely because a refractive error is detected. The associated-symptom profile showed bilateral headache in 54% and unilateral headache in 46%; photophobia and phonophobia were recorded in 9% and 8%, respectively, while nausea and vomiting were each recorded in 3%. The relatively low recording of migrainous symptoms may reflect the population, the method of data capture or incomplete documentation; it should not be used to exclude migraine without review of the clinical histories and formal diagnostic criteria. The presence of nasal symptoms or sinus tenderness likewise does not, by itself, establish a sinus-related cause of headache. No statistically significant associations were found between the recorded refractive-error-associated headache category and sex, age band, headache laterality or symptom duration in the exploratory analyses. These non-significant results do not demonstrate equivalence or rule out clinically meaningful associations. The sample was small for several subgroup comparisons, and the inclusion of out-of-range ages weakens applicability to the prespecified target population. In addition, the binary grouping combines heterogeneous alternative diagnoses, including migraine, sinusitis, asthenopia and unspecified headache; this limits the clinical specificity of comparisons. The clinical value of ophthalmological assessment is broader than identifying refractive error. A structured examination can assess visual acuity, refraction, ocular alignment, anterior segment, intraocular pressure when indicated and the optic nerve/fundus. In a large series of 1,878 children with headache, Lin et al. reported new ocular findings or findings potentially indicating occult neurological disease in 26.1%, including refractive issues, strabismus and optic nerve elevation; papilloedema was identified in a subset [7]. These findings support careful examination and appropriate referral when red flags or abnormal ocular findings are present, while avoiding the assumption that most headaches are caused by ocular pathology. Limitations: This analysis is limited by sample design along with small sample size and cross-sectional design.

Refractive-error-associated headache was the most frequently recorded diagnostic category in the supplied dataset, followed by migraine and sinusitis, underscoring the importance of considering both ophthalmological and primary headache disorders when evaluating children presenting with headache. However, the coexistence of refractive error and headache should not be interpreted as evidence of a causal relationship without appropriate clinical assessment and documentation of improvement following refractive correction where applicable. The analyses did not demonstrate statistically significant associations between the recorded diagnostic category and sex, age group, headache laterality or symptom duration. Further prospective studies involving verified, age-eligible participants and standardised headache and ophthalmological assessment are warranted to clarify the relationship between refractive errors and headache in children.

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