Case 94 · ICHD-3 11.3.2
11.3.2 Headache attributed to refractive error
- Origin
- Synthetic
- Language
- English — also available in German
- Contributed by
- Imported case — HeadAI synthetic vignettes (de Andrade JBC, da Silva Costa TB, Vasconcelos JL, Lopes TLM, Balsells MD, Cristofolini VL, Querobin SO, Filho FMR. Validation of an AI-based platform for structured diagnosis of headache disorders using ICHD-3 criteria. BMC Neurology 25, 489 (2025). doi:10.1186/s12883-025-04473-1. Dataset: Andrade J. Head.AI Platform. Mendeley Data, V2 (2025). doi:10.17632/4fms6cw2s5.2)
Anamnesis
Identification: Male patient, 22 years old, university student, reports bilateral frontal headache for 3 months, associated with prolonged computer use.
Disease History:
Pain:
Type: Bilateral frontal pressure or tightness, non-pulsatile, mild to moderate intensity.
Duration: 4–6 hours/day, progressively worsening throughout the day (especially after reading or screen use).
No nausea, vomiting, photophobia, or phonophobia (excluding migraine).
Associated factors:
Visual fatigue ("asthenopia") – blurred vision after prolonged visual effort.
Squinting ("screwing eyes") to improve focus.
No previous history of primary headaches.
Physical and Neurological Examination:
Visual acuity (uncorrected):
OD: 20/40 | OS: 20/50.
Static refraction (retinoscopy):
Bilateral myopia (OD: -2.50 D; OS: -2.75 D).
Fundoscopy: Normal, no papilledema or retinal changes.
Neurological examination: No motor, sensory, or pathological reflex abnormalities.
Report this case — e.g. suspected re-identification risk.