From the Guidelines
A thorough physical examination for migraines is essential to exclude secondary headache disorders and should include vital signs, a complete neurological assessment, and examination of potential trigger points. The physical examination is most often confirmatory, and further investigations are occasionally required to confirm or reject suspicions of secondary causes for headache 1. When performing a physical exam for migraines, it is crucial to begin with blood pressure and temperature to rule out hypertensive crisis or infection. The neurological exam should assess cranial nerves, motor strength, reflexes, coordination, and sensory function to exclude other neurological conditions.
- Pay special attention to the head and neck, checking for tenderness over the temporal arteries, sinuses, temporomandibular joint, and cervical muscles which may indicate alternative diagnoses or contributing factors.
- Examine the eyes, including fundoscopy to rule out papilledema which might suggest increased intracranial pressure.
- Auscultate for carotid bruits which could indicate vascular issues. While the physical exam is often normal in migraine patients, these steps are crucial to exclude secondary headache disorders like meningitis, stroke, or intracranial masses 1. The exam findings, combined with a detailed history of headache characteristics, triggers, and associated symptoms, help distinguish migraines from other headache types and guide appropriate treatment. According to the latest guidelines, suspicion of migraine should be strengthened by a family history of migraine and if onset of symptoms is at or around puberty 1.
From the Research
Physical Exam for Migraines
- A physical examination is a valuable tool in evaluating patients with migraines, as it can help identify the extracranial causes of headache and reassure both the patient and examiner that the headache is benign and treatable 2.
- The diagnosis of migraines is made by a careful history and physical examination, and imaging is generally not warranted 3.
- A skilled physical examination remains an important component of patient evaluation, even in settings where imaging and laboratory tests are easily available 4.
Importance of Physical Examination
- The physical examination can help narrow down or establish a diagnosis, and is beneficial for the physician-patient relationship 4.
- Identifying the extracranial origins of the patient's headache by physical examination can lead to physical treatment, reducing headache frequency and severity 2.
When to Perform Neuroimaging
- There is no necessity to perform neuroimaging in patients with headaches consistent with migraine who have a normal neurologic examination, and there are no atypical features or red flags present 5.
- Neuroimaging may be considered for presumed migraine in certain situations, such as unusual, prolonged, or persistent aura, or increasing frequency, severity, or change in clinical features 5.