The eight basic steps of a neurological exam
The neurological portion of your assessment of a patient with headache can give you important clues and must be undertaken carefully and diligently
- Mental status
- Cranial nerves
- Motor system
- Deep tendon reflexes
- Pathological reflexes
- Sensory system
- Gait and station
Patients with primary headache disorders will most likely have normal examinations, but when an abnormality is found, you should attempt to localise the abnormality in the nervous system and pinpoint its cause (e.g., disease process, etc.). In these circumstances, it is important to obtain neuroimaging studies.
Cranial nerve abnormalities
Migraine phenomena can uncommonly affect extraocular movements, producing diplopia which may last for several minutes or even hours, and may culminate in an ophthalmoplegic migraine.
However, diplopia can also be a sign that cranial nerves II, III, IV, and VI are involved in the disruption of extraocular movements.
Diplopia should be examined by imaging if it’s a new finding for the patient, or if it has significantly changed from prior presentations. Imaging should also be done if the diplopia is no longer associated with a headache, when it always occurred with a headache previously. Magnetic resonance (MR) angiography can be used to exclude masses, strokes, aneurysms, and stenosis in the posterior circulation.
Facial paraesthesia and facial muscle weakness
Facial paraesthesia and facial muscle weakness, affecting cranial nerves V or VII, may be seen with some migraine auras. These symptoms can occur with the headache and may or may not precede the headache pain. There can be lid drooping, mild facial asymmetry, and / or positive sensory changes experienced in the face that are not usually present with a patient’s migraine.
Papilloedema of the optic nerve
All patients should have a fundoscopic exam to look for papilloedema of the optic nerve, or cranial nerve II, which suggests increased intracranial pressure. If papilloedema is present, either a computed tomography (CT) scan or magnetic resonance imaging (MRI) is needed to differentiate an intracranial mass from pseudotumour cerebri. A mass could potentially lead to cerebral herniation. If it is confirmed that no mass is present, a lumbar puncture is needed to measure opening pressure and diagnose pseudotumor cerebri
Is there evidence of Horner syndrome during a headache event? This includes ptosis, miosis, tearing, pain, nasal stuffiness, and discharge. This may be seen with cluster headaches or benign paroxysmal hemicrania. It can also be seen with carotid artery disease which can affect the sympathetic fibres on the outside of the carotid artery
Motor and sensory abnormalities
You may find some motor and sensory abnormalities when examining a patient with headache. For example, limb or body paraesthesia with or without weakness can occur as an aura before or during a headache. However, focal abnormalities in the motor or sensory examination may indicate structural abnormalities in the nervous system.
Vertigo and headaches
Vertiginous migraine is controversial, but it has been identified in numerous circumstances. Originally it was thought to be primarily a paediatric phenomenon, but it has been increasingly recognised and possibly represents a basilar migraine type (i.e., a headache that originates in the brainstem). Patients with basilar migraines typically exhibit symptoms such as dizziness, nausea and vomiting, diplopia, ataxia, nystagmus, and diaphoresis.
It can be difficult to differentiate between a basilar migraine, benign paroxysmal positional vertigo, and stroke. Symptoms may occur without headache, as a prodrome, with headache, or as a postdromal event. Patients will note symptoms in close temporal proximity to the headache in most cases.
Be sure to ask about photophobia and phonophobia. Vertigo may be part of the aura, or there may be other auras present before the vertigo phase. To make the diagnosis of vertiginous migraine, posterior fossa tumours, seizures, and vestibular disorders must be excluded.
A consideration for managing vertiginous headaches Patients will sometimes experience regular migraines and sometimes experience vertiginous migraines. We treat these patients with migraine prophylactic medications and trigger avoidance.
Triptan medication packages contain inserts which caution against the use of triptans in basilar migraine. There is controversy over the use of triptans, with many researchers suggesting that there is no credible evidence showing basilar vasospasm with triptan use.
- The International Classification of Headache Disorders 3rd edition
- Donohoe CD. The role of laboratory testing in the evaluation of headache. Med Clin North Am. 2013 Mar;97(2):217-24.
- Lester MS, Liu BP. Imaging in the evaluation of headache. Med Clin North Am. 2013 Mar;97(2):243-65.
- Rizzoli P, Mullally WJ. Headache. Am J Med. 2018 Jan;131(1):17-24.
Neurology Library: Headache – History, Examination and Investigation
- Coni R. Characterising headache. LITFL
- Coni R. Headache history. LITFL
- Coni R. The headache diary. LITFL
- Coni R. Headache triggers. LITFL
- Coni R. Physical examination. LITFL
- Coni R. Neurological examination. LITFL
- Coni R. Headache and imaging. LITFL
- Coni R. Headache and laboratory tests. LITFL
Robert Coni, DO, EdS, FAAN. Vascular neurologist and neurohospitalist and Neurology Subspecialty Coordinator at the Grand Strand Medical Center in South Carolina. Former neuroscience curriculum coordinator at St. Luke’s / Temple Medical School and fellow of the American Academy of Neurology. In my spare time, I like to play guitar and go fly fishing. | Medmastery | Linkedin |
BMBS (The University of Nottingham) BMedSci (The University of Nottingham). Emergency Medicine RMO at Sir Charles Gairdner Hospital Perth, WA. Interested in Medical Education and Emergency Medicine. Swimmer and frequent concert attendee.