Headache History & Examination

Causes of Primary Headache

• Contraction of the muscles that cover the skull
• Physical or emotional stress
• Dehydration

History Taking

• Age at onset
• Presence or absence of aura and prodrome?
• Frequency, intensity, and duration of attack
• Number of headache days per month
• Family history of migraine

Associated Symptoms and Conditions

• Fever

  • Systemic infection: meningitis, encephalitis, brain abscess, otitis media.

• Vomiting

  • Mass lesion, brain abscess, migraine, carbon monoxide poisoning.

• Seizure

  • Mass lesion, stroke, meningitis, encephalitis, metabolic, toxic.

• Dizziness

  • Ischaemic or haemorrhagic infarct (posterior fossa), migraine.

• Neck Pain

• Meningitis, subarachnoid haemorrhage, tension headache, musculoskeletal pain (cervical paraspinal muscle pain).

• Facial Pain

  • Temporal area: Giant cell arteritis, trigeminal neuralgia
  • Eye area: Glaucoma
  • Ear area: Otitis media, Sinusitis.

• Visual Disturbance

  • Migraine, acute angle-closure glaucoma.

Physical Examination

• The majority of patients with a headache will have a normal physical examination. There are a few clues and important aspects of the physical examination that require close attention.

Vital Signs

• Elevated BP: consider hypertensive emergency, hypertensive urgency
• Temperature: consider infectious source.

Head, Eyes, Ears, Nose, and Throat (HEENT)

• Listening for bruit at neck, eyes, and head: atrioventricular malformation

• Palpation of head and neck for tenderness: paraspinal muscle tenderness/tension headache

• Tenderness over frontal and/or maxillary sinuses: consider sinusitis

• Tenderness Over Temporomandibular Joint (TMJ)

• TMJ dysfunction

• Neck stiffness/meningismus: meningitis

• Palpation of temporal artery for tenderness: giant cell arteritis

• Fundoscopy and Snellen chart: papilloedema (causes of raised intracranial pressure)

• Dental examination: caries/wisdom tooth impaction

• Ear examination: otitis media.

Focused Physical Examination

• Extracranial structure evaluation such as carotid arteries, sinuses, scalp arteries, cervical paraspinal muscles

• Examination of the neck in flexion versus lateral rotation for meningeal irritation.

  Even a subtle limitation of neck flexion may be considered an abnormality.

Neurological Examination

• Assessment of orientation, consciousness (Glasgow coma scale), presence of confusion and memory impairment

• Ophthalmology examination to include pupillary symmetry and reactivity, optic fundi, visual fields, and ocular motility

• Cranial nerve examination to include corneal reflexes, facial sensation, and facial symmetry

• Symmetrical muscle tone, strength (may be as subtle as arm or leg drift), or deep tendon reflexes

• Sensation

  • Plantar response(s): gait, arm, and leg coordination
  • Abnormal plantar reflex (Babinski’s sign): positive in central nervous system lesions

• Painful knee extension with hip flexed (Kernig’s sign); 5% positive in meningism.

  • Hip flexion with neck flexion (Brudzinski’s sign): 5% positive in meningism.