What is the appropriate physical assessment for an adult patient with no significant medical history presenting with a headache?

Physical Assessment for Headache in Adults

The physical assessment for an adult presenting with headache must include a thorough neurological examination and vital signs to identify "red flags" that distinguish benign primary headaches from life-threatening secondary causes, as this directly impacts morbidity and mortality. 1, 2

Essential Components of the Physical Examination

Vital Signs and General Assessment

• Measure blood pressure to detect hypertension, which may indicate increased intracranial pressure or hypertensive emergency 2, 3
• Assess temperature to identify fever suggesting meningitis, encephalitis, or other infectious causes 2, 3
• Evaluate general appearance for signs of distress, altered mental status, or systemic illness 3, 4

Comprehensive Neurological Examination

A complete neurological examination is mandatory and takes less than 3 minutes to perform 5:

• Fundoscopic examination to detect papilledema, which indicates increased intracranial pressure and requires immediate neuroimaging 2, 3, 5
• Cranial nerve assessment to identify focal deficits such as CN III, IV, or VI palsies suggesting mass lesion, or Horner's syndrome suggesting carotid dissection 2, 5
• Motor and sensory testing to detect focal neurological deficits or weakness that mandate immediate imaging 2, 3
• Cerebellar function testing including finger-to-nose, heel-to-shin, and rapid alternating movements to identify posterior fossa pathology 2
• Gait evaluation to detect ataxia or coordination problems 2
• Mental status assessment to identify personality changes, confusion, or cognitive deficits 2, 3

Head and Neck Examination

• Palpate temporal arteries for tenderness, nodularity, or absent pulse in patients over age 50 to evaluate for temporal arteritis 2, 6
• Assess neck stiffness (meningismus) to identify meningitis or subarachnoid hemorrhage 3, 4
• Examine sinuses for tenderness, though recognize that "sinus headache" is commonly misdiagnosed migraine 1
• Palpate cervical spine and paraspinal muscles for tenderness or trigger points 5

Critical Red Flags Requiring Immediate Action

Any of the following findings mandate urgent neuroimaging and specialist evaluation 2, 6, 3:

• Papilledema on fundoscopy indicates increased intracranial pressure 2, 3
• Focal neurological deficits including motor weakness, sensory loss, or cranial nerve palsies 2, 3
• Altered mental status or personality changes 2, 3
• Neck stiffness suggesting meningitis or subarachnoid hemorrhage 3, 4
• Abnormal vital signs including fever with headache or significantly elevated blood pressure 2, 3

Clinical Decision Algorithm

Normal Examination Findings

• If the neurological examination is completely normal and no red flags are present in the history, the patient likely has a primary headache disorder (migraine, tension-type, or cluster headache) 1, 2, 3
• Neuroimaging is NOT indicated for patients with normal examination and typical primary headache features, as the diagnostic yield is less than 1% 2, 7
• Proceed with classification based on International Headache Society criteria and initiate appropriate treatment 1

Abnormal Examination Findings

• ANY abnormal neurological finding requires neuroimaging 2, 3
• MRI brain without contrast is the preferred imaging modality for non-emergent evaluation 2, 7
• CT head without contrast is appropriate for acute evaluation when subarachnoid hemorrhage or acute hemorrhage is suspected 3, 4
• Immediate emergency department referral is required for thunderclap headache, papilledema, focal deficits, or altered mental status 2, 8

Common Pitfalls to Avoid

• Do not skip fundoscopic examination, as papilledema is a critical finding that indicates increased intracranial pressure and requires immediate action 2, 3, 5
• Do not dismiss headache in patients over age 50 without thorough evaluation for temporal arteritis, mass lesions, or other serious pathology 2, 8, 6
• Do not order routine neuroimaging without red flags, as this has extremely low yield and is not cost-effective 1, 2, 7
• Do not diagnose "sinus headache" without considering migraine first, as cranial autonomic symptoms are common in migraineurs and frequently lead to misdiagnosis 1, 7
• Do not rely solely on imaging results to exclude serious pathology; clinical assessment remains paramount 7, 5

Special Considerations

Patients Over Age 50

• New headache after age 50 requires urgent assessment for temporal arteritis (check ESR/CRP), mass lesions, or stroke 2, 8, 6
• Temporal artery examination is particularly important in this age group 6, 5

Medication Overuse Assessment

• Document all medication use including over-the-counter analgesics, as medication overuse headache should be suspected in patients taking analgesics more than 10 days per month 8, 9