What components should be included in the physical examination of a 26‑year‑old woman with migraine headaches?

Physical Examination for a 26-Year-Old Female with Migraine Headaches

The physical examination in migraine is primarily confirmatory and most often normal; its main purpose is to identify red flags that suggest secondary headache disorders requiring urgent investigation. 1

Essential Components of the Physical Examination

Neurological Examination

• Complete neurological assessment to detect any focal deficits, as abnormal neurological findings significantly increase the likelihood of serious intracranial pathology (likelihood ratio 5.3) and warrant immediate neuroimaging 2
• Cranial nerve examination to identify palsies, Horner's syndrome, or papilledema—any of which indicate secondary causes 3
• Motor and sensory testing to detect unilateral weakness or sensory loss that could suggest stroke, TIA, or structural lesions 4, 5
• Coordination testing (finger-to-nose, heel-to-shin, gait assessment), as uncoordination may indicate cerebellar pathology 1, 5
• Mental status assessment including memory, consciousness level, and personality changes, which if impaired suggest secondary headache 4, 5

Fundoscopic Examination

• Assess for papilledema, which indicates increased intracranial pressure from mass lesions, idiopathic intracranial hypertension, or other space-occupying processes 4, 5
• Look for retinal hemorrhages that may suggest subarachnoid hemorrhage or other vascular pathology 6

Meningeal Signs

• Neck stiffness assessment (resistance to passive flexion), as this is a critical red flag for meningitis or subarachnoid hemorrhage 1, 5
• Limited neck flexion is part of the Ottawa SAH Rule and requires immediate investigation 5
• Kernig's and Brudzinski's signs if meningitis is suspected 6

Vital Signs and General Examination

• Temperature measurement, as unexplained fever suggests meningitis or other infectious/inflammatory processes 1, 5
• Blood pressure to identify hypertensive crisis or other vascular causes 6
• General appearance for signs of systemic illness, weight loss, or cachexia 5

Head and Neck Examination

• Temporal artery palpation in any patient over 50 years (though this patient is 26) to assess for tenderness, nodularity, or absent pulse suggesting giant cell arteritis 4, 7
• Scalp palpation for tenderness or masses 6
• Sinus palpation and percussion to evaluate for sinusitis, though "recurrent sinus headache" often represents migraine 8
• Temporomandibular joint assessment for clicking, tenderness, or limited range of motion 6

Ophthalmologic Assessment

• Visual acuity testing to detect any acute changes 6
• Pupillary examination for asymmetry, fixed mid-dilated pupil (acute angle-closure glaucoma), or Horner's syndrome 7, 3
• Extraocular movements to identify diplopia or cranial nerve palsies 3

What a Normal Examination Confirms

In a patient with typical migraine features and a completely normal physical examination, the probability of finding serious intracranial pathology is extremely low (0.2%, equivalent to asymptomatic volunteers at 0.4%), and neuroimaging is not routinely indicated. 4

Critical Red Flags on Physical Examination

These findings mandate immediate further investigation:

• Focal neurological deficits (weakness, sensory loss, coordination problems) 1, 5
• Papilledema 4, 5
• Altered consciousness or impaired memory 4, 5
• Neck stiffness or limited neck flexion 1, 5
• Fever 1, 5
• Abnormal cranial nerve findings 3

Common Pitfall to Avoid

Do not order neuroimaging based solely on patient anxiety or "just to be sure" when the history is typical for migraine and the physical examination is completely normal—this exposes the patient to unnecessary radiation (if CT), cost, and the risk of discovering clinically insignificant incidental findings that lead to further unnecessary testing. 1 The examination's primary value is identifying the specific red flags listed above that genuinely warrant imaging. 1