PO-06 | Children’s headache through drawings: a narrative review and a portrait gallery

Floriana Ferro,^1,2 Caterina Gaspari,^1,2 Giulia Manfrè,^1,2 Federica Cernigliaro,¹ Daniela D’Agnano,³ Ruben Panzica,⁴ Edvige Correnti,² Maria Rosita Ruta,⁵ Francesca Marchese,⁵ Renata Pitino,² Maria Rita Capizzi,² Giuseppe Santangelo,² Antonella Versace,⁶ Vittorio Sciruicchio,³ Vincenzo Raieli² | ¹Child Neuropsychiatry Unit Department, Pro.MI.S.E. "G. D'Alessandro", University of Palermo; ²Child Neuropsychiatry Department, ISMEP, ARNAS Civico, Palermo; ³Children Epilepsy and EEG Center, San Paolo Hospital, ASL Bari, Bari; ⁴Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Messina; ⁵Child Neuropsychiatry Unit, ASP 6, Palermo; ⁶Pediatric Headache Center, Pediatric Emergency Dept, Regina Margherita Children's Hospital, Turin, Italy

Background: Headache is among the most common and disabling conditions in pediatric age, affecting mental and psychological well-being, as well as academic and social functioning, thus significantly reducing quality of life. Diagnosis currently relies on the criteria of the third edition of the International Classification of Headache Disorders (ICHD-3). However, pediatric headache presents diagnostic challenges due to children’s limited ability to describe pain and associated symptoms accurately. Younger children, especially those with underdeveloped or absent verbal communication, often struggle to express their experiences, complicating phenotype identification and clinical evaluation.

Methods: Clinical psychology has long employed drawing as a diagnostic tool to overcome communication barriers. Drawing provides a unique window into a child’s emotional and cognitive world, often revealing clinically relevant details that verbal reports may miss. The limited number of studies available in the literature support this approach, indicating that headache-related drawings may provide diagnostic accuracy and specificity comparable to standard clinical methods. Our narrative review compiles and analyzes the literature supporting the diagnostic value of drawings in pediatric headache and collects a visual archive of headache-related drawings to identify recurring graphic elements associated with specific clinical characteristics.

Results: The review highlights consistent graphic differences in the way children represent various headache types. These include distinctions in pain location, intensity, quality, presence of migraine aura, and associated symptoms such as nausea, vomiting, photophobia, and phonophobia. The visual patterns observed across multiple studies suggest that children’s drawings can serve as reliable indicators of headache phenotype. Moreover, drawing is reported as an enjoyable, non-invasive, low-cost, and easy-to-administer tool that can be used not only during the diagnostic phase but also in follow-up evaluations.

Conclusion: We propose a visual and narrative framework that supports clinicians in interpreting pediatric drawings as part of the diagnostic process for headache. Integrating drawing into routine clinical practice may enhance diagnostic precision, facilitate communication with younger patients, and promote a more child-centered model of care. Furthermore, we aim to introduce new iconographic models to assist clinicians in decoding specific graphic features related to different headache types, ultimately improving personalized care strategies for children.