Headache physical examination

Every headache patient will require a full neurological examination. In these articles we’ll briefly cover the components of a complete neurological exam and we’ll look at possible neurological abnormalities that might be found upon examination.

Examining the headache patient

In general, most patients with headaches have relatively normal examinations. However, here we review some potential findings that should make you think of a more sinister aetiology for your patient’s headache.

Vital signs

Blood pressure

Cerebral blood flow is proportionally linked to blood pressure. When blood pressure increases, the intracranial blood volume is increased which increases intracranial pressure, resulting in headaches (particularly during a hypertensive crisis). More importantly, a sudden severe headache with elevated blood pressure may be indicative of a hemorrhagic stroke. Uncontrolled hypertension can cause blood vessels to rupture resulting in haemorrhage.

Temperature

An elevated body temperature can be associated with systemic illness. For example, an infection like meningitis can produce a headache.

Heart rate

Changes in heart rate and rhythm can also indicate various medical illnesses that may produce secondary headache, such as atrial fibrillation with stroke. Tachycardia can be an indication of infection, other medical illness, or it could just be a marker for severe pain from the headache

Cardiac and respiratory examination

• Auscultation of the heart may give clues to general health and the presence of vascular disease.
• Examination of the lungs can give clues about ventilation and uncover underlying infection.
• Auscultate the carotid arteries and the eyes for bruits.
• Palpate the temporal arteries for ropiness and to assess the pulse which may be lost in temporal arteritis.

Head and neck

Observation and palpation of the head and neck of a patient with headache will help to identify trigger points, trauma, infection, and disorders of the glands or joints in this region.

Trigger points

The sinuses and muscles of the head and neck must be palpated to look for tender areas. Are there any trigger points in the strap muscles or temporalis muscles? Also assess for active trigger points in the muscles of the neck, and around the shoulders, including the rhomboids and trapezius. This search may lead the skilled examiner to extend the examination into the upper extremities and torso.

Trauma or infection

Check for signs of trauma or infection. Check the range of motion of the cervical spine and stress the facets and ligaments by hyperextending the neck while the head is bent to each side. If there is any restricted range of motion that is deemed to indicate nuchal rigidity, this may indicate meningeal irritation from blood or infection.

Thyroid gland

Palpate the thyroid gland for nodules and enlargements

Temporomandibular joint (TMJ)

Lastly, palpate the temporomandibular joint (TMJ) during opening and closing. Is there a click? Does the mandible slide or translocate? Does the jaw open widely?

References

• 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