8 year old son with anisocoria, migraines and eye tic

Hello, My son was recently seen for his first eye exam.  The examination assistant noticed he had one pupil larger than the other in the very dim light of the exam room, and then the doctor told me it was anisocoria, explaining, "it could be nothing, or it could be a sign of something life threatening."  Ok, so that's kind of a big range!

After asking me questions related to whether or not he sweats on both sides of his face when he exercises, and gets red on both sides of his face when he is angry (both answers: yes), the doctor said he thought it was likely nothing, and we should not worry about it.  The problem is, my son had just a month earlier, developed a severe eye tic (chronic blinking and twitching of both eyes) out of nowhere, and his migraine headaches have gotten very frequent -- having about 2-3 every month!  

I am trying not to be a worrying mother, but I am very concerned that something could be wrong, and if there is, I want to figure this out as early as possible!  Do these symptoms all together sound like something I should be concerned about?

Thanks,
Liza  

[Sandra M Brown, MD]

The vast majority of children with anisocoria have "physiologic" or "benign" anisocoria.  If the parents haven't noted it before, this doesn't mean that it wasn't there.  The "bad" kind of anisocoria in an 8 year old would almost always be accompanied by slight drooping of the upper lid on the side of the SMALLER pupil.  This combination of signs is known as Horner Syndrome and it may rarely be caused by neuroblastoma, which is a tumor that affects the nerves that control the pupil and eye lid.

However in an otherwise healthy 8 year old with only anisocoria, I would not worry and I would not pursue any additional investigations.

The blinking tic and the migraines are likely both stress responses.  Blinking tic is not part of Horner Syndrome.  Blinking tic has involuntary and voluntary components.  The best way to make a blinking tic a whole lot worse is to pay attention to it.  Boys are more likely to tic than girls and 6 - 8 years is a common age for the problem to start.

I would suggest that you see your pediatrician about stress and anxiety management.

[lizashaw]

Thank you, Dr. Brown ~
Is it possible that the migraines are causing the anisocoria, or vise versa?  Is there any treatment for migraines in children?  Both I and my husband have suffered with migraines most of our lives, and we both have taken meds for them.  

We have treated my son for anxiety during a very stressful period in the past, with play therapy, and it was very helpful.  I think I will bring him back.  But, I have done some reading on eye tics and it seems the popular medical belief right now is that while tics get worse when a child is under stress, psychotherapy is a misdirected treatment.  Most of what I have read says that tics are a neurological problem.  I hesitate to medicate my 8 year old for anything, especially with any kind of serious medication.  What is your opinion on this?