What are key takeaway learnings about head physical examinations for headache diagnosis and management, including primary headache disorders like migraines?

Key Takeaways for Head Physical Examination in Headache Evaluation

Takeaway 1: Medical History Trumps Physical Examination—But the Neurological Exam Identifies Life-Threatening Red Flags

The medical history is the cornerstone of headache diagnosis, but a meticulous neurological examination is mandatory to distinguish benign primary headaches from secondary causes that can kill or disable patients. 1, 2

Essential History Components

• Age at onset, duration, frequency, and pain characteristics (location, quality, severity, aggravating/relieving factors) are essential for applying diagnostic criteria 1
• Accompanying symptoms including photophobia, phonophobia, nausea, vomiting, and aura symptoms must be systematically documented 1
• Family history of migraine strengthens suspicion for primary headache disorders, as migraine has a strong genetic component 1
• Medication use history is critical—regular use of analgesics ≥10 days/month or other acute medications ≥10 days/month for >3 months defines medication-overuse headache 1

Critical Neurological Examination Elements

The American College of Radiology mandates these specific components for pediatric patients (principles apply to adults): 2

• Vital signs with blood pressure measurement—hypertension can indicate increased intracranial pressure or other serious pathology 2
• Comprehensive cranial nerve assessment—94% of children with brain tumors have abnormal neurological findings at diagnosis, with 60% showing papilledema 1, 2
• Fundoscopic examination of optic discs—papilledema is a critical red flag for increased intracranial pressure 2
• Motor and sensory testing, cerebellar function, gait evaluation, and mental status assessment 2

Common Pitfall

Never skip fundoscopic examination—it is essential for detecting increased intracranial pressure, and its omission can result in missed life-threatening diagnoses like brain tumors or idiopathic intracranial hypertension. 2

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Takeaway 2: Recognize Primary Headache Patterns to Avoid Unnecessary Neuroimaging—But Know When Imaging Is Mandatory

Primary headaches (migraine, tension-type, cluster) account for the vast majority of headaches and do not require neuroimaging when the examination is normal, as the yield is <1% for clinically significant findings. 1, 2

Migraine Without Aura Recognition

Suspect migraine without aura when: 1

• Recurrent moderate to severe headache with unilateral and/or pulsating pain
• Accompanying symptoms: photophobia, phonophobia, nausea, and/or vomiting
• Onset at or around puberty with positive family history strengthens the diagnosis 1

Migraine With Aura Recognition

• Recurrent, short-lasting visual and/or hemisensory disturbances followed by headache within 60 minutes 1

Chronic Migraine Recognition

• ≥15 headache days per month for >3 months, with migraine features on ≥8 days per month 1

Tension-Type Headache Recognition

• Bilateral pressing/tightening quality, mild to moderate intensity, lacking autonomic features 3

Cluster Headache Recognition

• Severe unilateral supraorbital or temporal pain lasting 15-180 minutes with ipsilateral autonomic symptoms (lacrimation, rhinorrhea, ptosis) 3
• Frequency of 1-8 attacks daily occurring in clusters, with patients pacing rather than lying still (unlike migraine) 3

Common Misdiagnosis to Avoid

"Sinus headache" is a common misdiagnosis among pediatric and adult migraineurs—approximately 62% of pediatric migraineurs have cranial autonomic symptoms (rhinorrhea, nasal congestion) from trigeminal-autonomic reflex activation, mimicking sinusitis. 1 Consider migraine with cranial autonomic symptoms first in patients with recurrent headaches and sinus symptoms. 1

When Neuroimaging Is NOT Indicated

• Primary headaches with normal neurological examination and no red flags do not require neuroimaging 1, 2
• In pediatric studies, only <1% of imaged children with primary headaches had relevant findings to explain the headache 1

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Takeaway 3: Apply a Systematic Red Flag Framework—Abnormal Findings Mandate Immediate Neuroimaging

Any abnormal neurological finding on examination mandates emergent neuroimaging, as nearly all patients with serious intracranial pathology have examination abnormalities. 1, 2

Absolute Red Flags Requiring IMMEDIATE Imaging

The American College of Radiology and other guidelines identify these examination findings: 2, 4, 5

• Papilledema on fundoscopy—indicates increased intracranial pressure 2
• Focal neurological deficits (motor weakness, sensory loss, cranial nerve palsies) 2, 4
• Altered mental status or impaired consciousness 4
• Abnormal gait, cerebellar signs, or abnormal reflexes 1
• Meningeal irritation on physical examination (nuchal rigidity, Kernig's/Brudzinski's signs) 4

Historical Red Flags Requiring Imaging (Even With Normal Exam)

• "Thunderclap" headache (sudden onset, peaking within seconds to 1 minute)—requires immediate CT to exclude subarachnoid hemorrhage 6, 4
• New headache after age 50—requires urgent assessment for temporal arteritis, mass lesions, or stroke 6
• Progressively worsening headache over days to weeks suggests evolving pathology 6, 4
• Headache awakening patient from sleep may indicate increased intracranial pressure 6
• Headache worsened by Valsalva maneuver (coughing, straining, bending) suggests increased intracranial pressure 6, 5
• Fever with headache—requires urgent evaluation for meningitis or encephalitis 6

Imaging Algorithm

• CT without contrast for acute evaluation when immediate assessment is needed, particularly for suspected hemorrhage 1, 2, 4
• MRI without contrast is preferred for non-emergent evaluation of suspected tumor, stroke, or other structural lesions, with superior sensitivity 1, 2
• Lumbar puncture is needed to rule out subarachnoid hemorrhage if CT is normal in thunderclap headache 4

Critical Clinical Pearl

94% of children with brain tumors have abnormal neurological findings at diagnosis, and nearly all children with intracranial tumors have symptoms beyond isolated headache. 1, 2 This underscores that a normal neurological examination in primary headache is highly reassuring.