What does a full neuro exam for a pediatric patient with a severe headache consist of?

Neurological Examination Components for a 13-Year-Old with Severe Headache

A complete neurological examination for a pediatric patient with severe headache must include vital signs with blood pressure measurement, comprehensive cranial nerve assessment, fundoscopic examination of the optic discs, motor and sensory testing, cerebellar function, gait evaluation, and mental status assessment to identify red flags that distinguish benign primary headaches from life-threatening secondary causes. 1

Essential Initial Assessment Components

Vital Signs and General Examination

• Blood pressure measurement is mandatory, as hypertension can indicate increased intracranial pressure or other serious pathology 1
• Measure head circumference if there are concerns about increased intracranial pressure (though less relevant at age 13) 1
• Assess general appearance and level of consciousness 2

Complete Neurological Examination Elements

Mental Status Assessment:

• Level of consciousness and orientation 2
• Changes in mental status are a critical red flag requiring immediate neuroimaging 2
• Cognitive function appropriate for age 3

Cranial Nerve Examination:

• Fundoscopic examination of optic discs is specifically emphasized in guidelines to detect papilledema, which indicates increased intracranial pressure 1
• Visual fields and acuity 4
• Pupillary responses 4
• Extraocular movements 4
• Facial sensation and strength 4
• Hearing 4
• Gag reflex and palate elevation 4

Motor Examination:

• Muscle strength in all extremities 4
• Muscle tone 4
• Presence of any focal weakness (a red flag) 2

Sensory Examination:

• Light touch and pain sensation 4
• Proprioception 4

Cerebellar Function:

• Coordination testing (finger-to-nose, heel-to-shin) 4
• Rapid alternating movements 4

Reflexes:

• Deep tendon reflexes 4
• Plantar responses 4
• Asymmetry suggests focal pathology 2

Gait Assessment:

• Observe walking pattern 4
• Tandem gait 4
• Romberg test 4

Critical Red Flags Requiring Immediate Action

An abnormal neurological examination is the single most important predictor of significant intracranial pathology, with 50% of children showing abnormal neuroimaging findings when the neurological exam is abnormal. 5

Red Flags on History

• Severe or "worst ever" headache 1, 2
• Recent onset progressive headache (<6 months) 2
• Headache awakening child from sleep 2
• Intractable vomiting 2
• Age <6 years (though patient is 13) 2
• Occipital location 2
• Change in headache pattern 2
• Associated subjective vertigo 2

Red Flags on Examination

• Any abnormal neurological finding 1, 5
• Focal neurological deficits 2
• Papilledema on fundoscopy 1
• Signs of increased intracranial pressure 1
• Altered mental status 2

Clinical Decision-Making Algorithm

For severe headache with normal neurological examination:

• Primary headaches (migraine, tension-type) are most likely 1
• Neuroimaging has very low yield (<1% clinically significant findings) 1
• Consider observation and symptomatic treatment 1

For severe headache with ANY abnormal neurological finding:

• Emergent neuroimaging is mandatory 1, 5
• CT without contrast for acute evaluation if concerned about hemorrhage 1
• MRI is preferred for non-emergent evaluation of suspected tumor or other structural lesions 1

For worsening severe headache during observation:

• Emergent neuroimaging required 1
• Risk of intracranial complications increases with progressive symptoms 1

Common Pitfalls to Avoid

• Do not skip fundoscopic examination - this is specifically emphasized in guidelines as essential for detecting increased intracranial pressure 1
• Do not order routine neuroimaging without red flags - yield is <1% in children with normal examination and no concerning history 1
• Do not dismiss severe headache based solely on normal imaging - consider other causes like idiopathic intracranial hypertension requiring MR venography 1
• Do not confuse cranial autonomic symptoms (rhinorrhea, lacrimation) with sinusitis - 62% of pediatric migraineurs have these symptoms 1