Physical Assessment for Migraines
The physical examination for migraine should focus on excluding secondary causes through a complete neurological examination and identifying musculoskeletal and vestibular dysfunctions that may contribute to or coexist with migraine. 1, 2
Neurological Examination to Exclude Secondary Causes
The primary purpose of the physical examination is to identify red flags that suggest dangerous secondary etiologies requiring urgent workup:
- Perform a complete neurological examination including cranial nerves, motor strength, sensory testing, reflexes, coordination, and gait assessment 1, 3
- Focal neurological deficits (motor weakness, sensory loss, visual field defects) warrant immediate neuroimaging with MRI brain as the preferred modality 4, 5
- Abnormal neurological examination findings of any kind indicate need for urgent neuroimaging and/or specialist referral 5, 1
- Papilledema on fundoscopic examination suggests elevated intracranial pressure and requires emergent evaluation 1
- Meningeal signs (neck stiffness, Kernig's sign, Brudzinski's sign) with fever indicate possible infection requiring CSF examination 1
Musculoskeletal Assessment
Physical therapists and physicians should systematically examine the head and neck musculature, as extracranial muscle pain is a frequent contributor to migraine:
- Palpate the temporalis, masseter, sternocleidomastoid, trapezius, and suboccipital muscles for tenderness, trigger points, and referred pain patterns 2, 6
- Assess cervical range of motion in all planes (flexion, extension, rotation, lateral bending) and note any restrictions or pain provocation 2
- Examine for cervical spine dysfunction including joint mobility and alignment abnormalities 2
- Test for muscle tension and myofascial trigger points in the pericranial and cervical muscles, which are prevalent among individuals with migraine 2, 6
Vestibular and Balance Assessment
This is particularly important for patients with vestibular migraine or those reporting dizziness:
- Assess postural control and balance using standardized balance tests, as impairment is common in migraine patients 2
- Perform vestibular symptom screening including assessment for vertigo, dizziness, and motion sensitivity 7, 2
- Evaluate for nystagmus and perform positional testing if vestibular symptoms are present 7
- Document the presence of ipsilateral autonomic symptoms (lacrimation, conjunctival injection, nasal congestion, ptosis, miosis) to differentiate from cluster headache 4
Vital Signs and General Physical Examination
- Measure blood pressure and heart rate to identify hypertension or tachycardia that may contraindicate certain treatments or suggest secondary causes 7, 1
- Assess for systemic signs including fever, rash, or signs of infection that suggest secondary headache 5, 1
- Examine the temporal arteries for tenderness, nodularity, or absent pulse in patients over age 50 to exclude giant cell arteritis 1
Key Pitfalls to Avoid
The most common error is performing an inadequate neurological examination and missing red flags. Any abnormal finding on neurological examination mandates neuroimaging 5, 1. However, in primary migraine, the neurological examination should be completely normal between attacks 7, 3.
Another pitfall is failing to assess musculoskeletal and vestibular components, which are highly prevalent in migraine patients and represent treatable targets for physical therapy interventions 2, 6.