What are the key components of a physical assessment for an elderly patient with a history of hypertension and cardiovascular disease presenting with a headache?

Physical Assessment for Headache in Elderly Patients with Hypertension and Cardiovascular Disease

In an elderly patient with hypertension and cardiovascular disease presenting with headache, the physical examination must prioritize detection of life-threatening secondary causes—particularly giant cell arteritis, intracranial hemorrhage, and stroke—through focused assessment of vital signs, neurological status, fundoscopic examination, and vascular examination. 1, 2

Critical Vital Signs Assessment

Blood pressure measurement is essential at every encounter, as hypertensive urgency or emergency can manifest as headache. 3

• Measure BP in both arms; differences >20 mmHg systolic or >10 mmHg diastolic warrant investigation for vascular abnormalities 3
• Assess orthostatic blood pressure changes (supine and standing measurements) to evaluate for volume status and autonomic dysfunction 3
• Document heart rate at rest, as increased heart rate indicates elevated cardiovascular risk 3

Neurological Examination for Red Flags

A complete neurological examination is mandatory to identify focal deficits suggesting stroke, TIA, or space-occupying lesions. 1, 2

• Motor and sensory examination: Assess for focal weakness, sensory deficits, or asymmetry that may indicate stroke or structural lesions 3, 4
• Cranial nerve assessment: Evaluate all cranial nerves, particularly looking for CN III, IV, or VI palsies that may suggest cavernous sinus pathology or increased intracranial pressure 3
• Cognitive assessment: Screen for impaired memory, altered consciousness, or personality changes that strongly suggest secondary headache 2, 5
• Gait and balance testing: Particularly important in elderly patients, as instability may indicate cerebellar or posterior circulation involvement 3

Fundoscopic Examination

Fundoscopic examination is critical to detect papilledema, which indicates increased intracranial pressure requiring urgent intervention. 3, 2

• Look for papilledema (blurred disc margins, elevated optic disc, absent venous pulsations) 3, 2
• Assess for retinal hemorrhages or other vascular changes related to hypertension 3
• Document presence or absence of optic atrophy, which may indicate chronic elevated intracranial pressure 3

Vascular Examination

In patients over 50 years, temporal artery examination is essential to evaluate for giant cell arteritis, which can cause irreversible vision loss if untreated. 1, 2

• Palpate temporal arteries bilaterally for tenderness, nodularity, or decreased pulse 2, 6
• Assess for scalp tenderness by palpating the scalp, particularly over temporal regions 1, 2
• Auscultate carotid arteries for bruits suggesting atherosclerotic disease 3
• Palpate peripheral pulses (radial, femoral, dorsalis pedis) and assess for asymmetry or absence 3

Meningeal Signs Assessment

Neck stiffness with headache suggests meningitis or subarachnoid hemorrhage and requires immediate investigation. 1, 2

• Test for nuchal rigidity by passive neck flexion 1, 7
• Assess for Kernig's and Brudzinski's signs if meningeal irritation is suspected 7

Additional Focused Examination Elements

Weight and body mass index calculation should be documented, as obesity increases risk of idiopathic intracranial hypertension 3, 2

Cardiac auscultation for arrhythmias (particularly atrial fibrillation, which increases stroke risk) and murmurs 3

Respiratory examination for signs of sleep apnea (a modifiable risk factor worsening headache frequency), including observation for obesity and questioning about snoring 2

Key Examination Findings Requiring Urgent Action

The following findings mandate immediate further investigation:

• Papilledema → neuroimaging and possible lumbar puncture for intracranial pressure measurement 1, 2
• Focal neurological deficits → immediate neuroimaging to rule out stroke or mass lesion 1, 5
• Temporal artery tenderness with systemic symptoms → immediate ESR/CRP and consideration of temporal artery biopsy (note: ESR can be normal in 10-36% of giant cell arteritis cases) 1, 6
• Neck stiffness with fever → immediate evaluation for meningitis 1, 5
• Altered mental status → urgent neuroimaging and metabolic workup 2

Common Pitfalls to Avoid

Do not rely solely on ESR to exclude giant cell arteritis in elderly patients, as it can be normal in up to 36% of cases; clinical suspicion should drive temporal artery biopsy even with normal inflammatory markers. 1, 6

Do not assume headache awakening from sleep is benign in elderly patients—this pattern may indicate increased intracranial pressure from tumor or other space-occupying lesion. 1, 2

In elderly patients with vasculopathic risk factors (hypertension, cardiovascular disease), do not assume headache is benign without thorough examination—up to 15% of patients over 65 with new-onset headache have serious pathology including stroke, temporal arteritis, neoplasm, or subdural hematoma. 4, 6

3, 1, 2, 5, 4, 7, 6