You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


INTRODUCTION {#sec1-1}
============

Patients are frequently referred to ophthalmology department from pediatric care units for evaluation of refractive error in case of headache. While there are numerous causes of headache, uncorrected or under-corrected refractive errors have long been considered a potential cause of headache in pediatric population.[@ref1]Numerous studies have shown a significant relation between these two entities. However, the evidence base for this remains shallow, due to various studies showing no significant relationship.

Headache disorders are the most frequently encountered clinical entity. [@ref2] Headache has a profound effect on quality of life. This significantly hampers daily routine, affects mood and cognition and often leads to severe psycho-social issues.[@ref3] Headache is considered a disabling condition in pediatric age group, which, if not properly managed, can lead to long term effects on child's psychology and mental wellbeing.[@ref4] The international headache society has delineated headache due to refractive error in a methodical manner. It shows that headache is caused by uncorrected hyperopia or astigmatism. The headache is usually mild, more common in frontal region and is usually absent on waking up. The headache is reported to worsen with prolonged visual activity.[@ref5]With the disease entity so specifically described, it is imperative to consider this a yardstick for evaluation of children with unexplained headache not falling into any other category. A routine ophthalmic evaluation is perhaps mandatory.

To the researcher's knowledge, no study has been conducted in Pakistani population to measure the prevalence of uncorrected ametropia in children with persistent and un-explained headache. The aim of this study was to measure the frequency of uncorrected ametropia in children with 2 to 8 weeks of persistent headache referred to ophthalmic outpatient department for evaluation.

METHODS {#sec1-2}
=======

This cross sectional study was carried out at Combined Military Hospital (CMH) Gujranwala, from March 2018 to November 2018, after approval from the institutional ethical review committee, and taking written informed consents from parents of children included in the study. A total of 262 children from either gender, aged from 5 to 16 years, with 2 to 8 weeks history of persistent headache were included in the study. Children with history of squint, refractive error, head injury, trauma, intracranial space occupying lesions, sinusitis, migraine, prolonged drugs use, epilepsy, fever, and other known neurological diseases were excluded. All children had remained under evaluation of pediatrician for diagnosis of headache. Those with a certain diagnosis were also excluded from the study. All children received in ophthalmic department underwent evaluation of visual acuity, best corrected visual acuity after cycloplegic refraction, fundoscopy, assessment for squint using Hirschberg test and cover uncover test, stereopsis testing using Titmus test and detailed anterior and posterior segment examination. Those children diagnosed with ametropia were subsequently re-called for post mydriatic testing for best corrected visual acuity, and prescribed with glasses. They were re-evaluated after 4 weeks and 8 weeks of prescription of glasses for complaints of headache. Patients without any ophthalmic findings were referred back to pediatrics department for further evaluation.

The pre devised proforma was completed by researcher endorsing subject's demography and ocular examination findings. Confidentiality of the patient's record was maintained. Statistical Package for Social Sciences (SPSS 20.0) for windows was used for statistical analysis. Descriptive statistics i.e. mean ± standard deviation for quantitative values (age, duration of headache) and frequencies along with percentages for qualitative variables (gender, refractive errors) were used to describe the data. The children were further divided in two groups, with ametropia, and those without ametropia. After normality testing, qualitative variable like gender was compared between two groups using Chi Square test and quantitative variables like age and duration of headache were compared using independent 't' test. A p-value of ≤0.005 was considered statistically significant.

RESULTS {#sec1-3}
=======

A total of 262 children fulfilling the inclusion criteria were evaluated. Out of 262 children, 127 (48.5%) were males, and 135 (51.5%) were female. Mean age of study population was 8.97 ± 3.16 years. Mean duration of headache was 5.03 ± 1.81 weeks. Ametropia was found in 56 (21.4%) children, while 206 (78.6%) had no refractive error. Out of children with ametropia, 20 (35.7%) had myopia, 24 (42.8%) had astigmatism and 12 (21.5%) had hypermetropia. The comparison of groups (ametropia/no ametropia) with respect to age, gender and duration of headache is given in [Table-I](#T1){ref-type="table"}. There was no difference in ametropic children and children without ametropia with respect to gender (p=0.73), age (p=0.54) and duration of headache (p=0.71). After correction of ametropia, 35 (62.5%) children reported alleviation of headache after 4 weeks, and 42 (75%) reported alleviation in symptoms after 8 weeks. A total of 14 (25%) children reported headache even after correction of ametropia with glasses. Further discussion about causes of headache in study population is beyond the scope of this study.

###### 

Group wise demographic data (n=262).

  Characteristic                           Study Population (n=262)   Group-A (Ametropia) (n=56)   Group-B (No amteropia) (n=206)   p-Value
  ---------------------------------------- -------------------------- ---------------------------- -------------------------------- -----------------------------------------
  Age (Years) Mean ± SD                    8.96 ± 3.16                9.19 ± 3.38                  8.90 ± 3.10                      0.546[\*](#t1f1){ref-type="table-fn"}
  ***Gender***                                                                                                                      
   Male                                    127 (48.5%)                26(46.4%)                    101(49%)                         0.730[\*\*](#t1f2){ref-type="table-fn"}
   Female                                  135 (51.5%)                30(53.6%)                    105(51%)                         
  Duration of headache (weeks) Mean ± SD   5.03 ± 1.81                4.94 ± 1.84                  5.04 ± 1.80                      0.709[\*](#t1f1){ref-type="table-fn"}

Independent t-test,

Chi Square test

DISCUSSION {#sec1-4}
==========

The actual reason of headache due to ametropia remains en-explained. It is believed that contraction of ciliary muscles is effortless and should not lead to headache. Study by Cameron ME revealed that very few cases with headache had refractive error. They also found that in presbyopia and hypermetropia, headaches are infrequent. They postulated that headaches observed are due to associated contraction of the scalp muscles.[@ref6] Medical term for headache associated with eye strain or fatigue is asthenopia, which is thought to be triggered by ametropia, extra ocular muscle imbalance, improper reading or working environment and inaccurate reading or working habits.[@ref7] Another meta-analysis on the subject including 2465 subjects revealed that majority of children with asthenopia had no refractive error and estimated a pooled prevalence of ametropia of 19.7% in children.[@ref8]

Ophthalmologists are frequently referred cases for evaluation of refractive errors and diagnose ocular causes of headache. Many authors have divided causes of headache into ocular and non-ocular causes.[@ref9] While majority of these are related to asthenopia or refractive errors, other conditions like corneal ulcers, migraine, glaucoma, giant cell arteritis, idiopathic intracranial hypertension, sinusitis, hypertension and scleritis are also known to cause headache.[@ref10] This shows that all patients with headache must undergo complete ophthalmic evaluation.

The type of headache due to refractive errors varies and is mostly subjective. Some patients report a dull peri-ocular pain, while others report frontal headache of sharp nature. We included children with all sorts of headache, frontal, temporal, migraine like and cluster type. In a study by Gunes A and associates, it was found that migraine was a common type of headache in children with ametropia.[@ref11] Other types of headaches are also reported in relation to asthenopia. Orbell G gave hopeful results of treating children having eye strain with chlordiazepoxide in 1963.[@ref12] Thus headache due to eye strain is manageable, either with correction or with systemic treatment of headache.

In our study population, the prevalence of ametropia was found to be 21.4%. The total study population had included children with un-explained headache, refractory to medical treatment. In a large study including 1448 children with headache, 82.3% had a normal eye examination, while refractive errors, amblyopia, and strabismus were found in 15.0%, 3.6%, and 7.3%, respectively.[@ref13] In another study, headache was reported in 23.1% of schoolchildren and it was concluded that asthenopia was significantly associated with uncorrected visual acuity and myopia among schoolchildren.[@ref14] Another study conducted on child laborers working in gem polishing industries revealed that excessive near work lead to asthenopia or eye strain in as many as 32.2% children.[@ref15]

We found a significant number of children with headache suffering from uncorrected ametropia. In one study, it was recommended that headaches in children usually do not appear to be caused by ophthalmic disease, including refractive error.[@ref16] However, other studies have clearly described that compound and mixed types of astigmatism, anisometropia, and miscorrection of refractive error were found more often in patients with headache than in control subjects.[@ref17]Few studies comparing the children with headache with control group have concluded that headache is not associated with refractive errors, and proper correction of refractive errors significantly improved headache complaints and did so primarily by decreasing the frequency of headache episodes, rather than improvement on visual acuity.[@ref18],[@ref19] Further research in this regard will be helpful for defining a medical strategy for children with headache.

We found that out in children with ametropia, 20 (35.7%) had myopia, 24 (42.8%) had astigmatism and 12 (21.5%) had hypermetropia. This is in accordance with prevalence found by studies showing that low degrees of astigmatism and anisometropia are relevant in migraine and headache.[@ref20] In another study conducted in Israel, it was found that anisometropia and myopia were the most common refractive errors encountered, followed by hyperopia and astigmatism in children with headache.[@ref21]

We also found out that after correction of ametropia, 35 (62.5%) reported alleviation of headache after 4 weeks, and 42 (75%) reported alleviation in symptoms after 8 weeks. 14 (25%) reported headache even after correction of ametropia with glasses. This is in accordance with research conducted by Jeddi A et al.[@ref22] However, other studies have asserted that despite the apparent belief that provision of an appropriate correction may alleviate various types of headache, there is little robust evidence in support of this position.[@ref23] Authors presume that alleviation in symptoms of headache is a subjective feeling, that depends on response of children to optical correction. Exact and objective assessment in this regard will always remain doubtful and will warrant large cohort trials.

The study has limitations of not including a control group, and not discussing the details of ultimate diagnosis of headache in children without ametropia. Presumably, comparison with a control group will better explain the prevalence of ametropia in children.

CONCLUSION {#sec1-5}
==========

We conclude that a significant majority of children with un-explained headache have refractive errors. Proper evaluation of refractive error and full optical correction can help in improvement in headache for these children. Refractive errors should always be considered in differential diagnosis of all children who present to pediatrics outpatient with un-explained and refractory headache.

None.

***Conflict of Interest:*** None.

***Grant Support & Financial Disclosures:*** None.

Author\`s Contribution {#sec2-1}
======================

**MAM** did data acquisition, data analysis, manuscript writing.

**HN** did conception, design of study and manuscript writing.

**MK** did statistical analysis and manuscript editing.