6-year-old boy presents with intermittent headaches

A 6-year-old boy was referred to the New England Eye Center with symptoms of intermittent headaches for the last 3 months. The patient and his mother described the headaches as occurring three to four times per week, located primarily frontal and “on top of the head,” that would become progressively severe, lasting 1 to 2 hours, occasionally associated with nausea. Initially, it was thought the headaches may be related to concentrated activities such as reading. However, the pain was now occurring more often without any notable aggravating factors.The patient was seen by his primary care provider for these headaches 4 weeks prior, and he was started on as-needed ibuprofen and an antacid for the occasional nausea and gastrointestinal prophylaxis. After minimal improvement, he was referred to Tufts Neurology for further work-up. Before any additional work-up for the headaches, the neurologist asked that he have a baseline eye exam performed. The patient denied any diplopia, acuity changes or eye pain. The patient lives with both of his parents in suburban Massachusetts and has no significant medical or family medical history.