Examining the patient with headaches

Your patient's body will give you important clues that can point you to the cause of their headaches—if you know where to look! In this video, from our Headaches Masterclass, you'll learn how to decipher your patient's vital markers, as well as their cardiac and respiratory health, to determine how these may be contributing to your patient's headaches. We'll cover important signs to consider when performing a head and neck examination, and two things to watch out for when palpating trigger points.

Our Headaches Masterclass course outlines an approach that will guide your evaluation of the patient with headaches. It will provide you with the knowledge and skills you need to recognize and categorize primary headaches accurately, the warning signs of ominous headaches (and those caused by medical conditions), and will teach you how to help your patients to help themselves by recognizing their triggers and adopting lifestyle changes.

I will break down the important components of the physical examination for the headache patient. In general, most headache patients have relatively normal examinations. The whole body can contribute to headache in some patients, and this may be reflected in the vital signs. Vital signs are an important part of any physical examination, an abnormality in blood pressure, temperature, and heart rate can contribute to headaches.

Blood pressure elevation may be indicative of ischemia, or hemorrhage and stroke. Cerebral blood flow is proportionally linked to blood pressure. When the blood pressure fluctuates, the intracranial blood volume is altered which can alter pressure and result in a headache. An elevated body temperature can be associated with systemic illness.

For example, an infection like meningitis can produce a headache. Changes in heart rate and rhythm can also indicate various medical illnesses that may produce secondary headaches, such as atrial fibrillation with stroke. Tachycardia can be an indication of infection, other medical illness, or it could be a marker for severe pain from the headache itself.

Auscultation of the heart may give clues to general health and the presence of vascular disease. Examination of the lungs can give clues about ventilation and uncover underlying infection. Auscultate the carotid arteries and the eyes for bruits. Palpate the temporal arteries for ropiness and to assess the pulse which may be lost in temporal arteries.

The sinuses and muscles of the head neck must be palpated to look for tender areas. Are there any trigger points in the strap muscles? Or temporalis muscles? Are there any signs of trauma? Trigger points are discrete regions of a muscle that are firm to touch and produce discomfort when pressure is exerted on them.

There is frequently a distal sensory sign associated with the trigger point when it is stimulated. Sometimes when active it may provoke some distal symptom of pain, or paraesthesia. Look for tightness of the muscle with pain on palpation and paraesthesia in a region associated with that trigger point.

One should assess for active trigger points in the muscles of the neck and around the shoulders, including the rhomboids and trapezius. This search may lead the skilled examiner to extend the examination into the upper extremities and torso. Charts of common trigger points are available outlining these regions.

Check the range of motion of the cervical spine and stress the facets and ligaments. Do so by hyperextending the neck while the head is bent to each side. Nuchal rigidity may indicate meningeal irritation from blood or infection. Nuchal rigidity is demonstrated with the Brudzinski or Kernig signs. The Brudzinski sign is elicited by stretching meninges when flexing the neck forward and pain is produced.

The Kernig sign is elicited by extending the legs after the hips are flexed up, and pain is thus produced. Palpate the thyroid gland for nodules and enlargements. Palpate the temporalmandibular joint during opening and closing, is there a click? Does the mandible slide or translocate? Does the jaw open widely? In the next Medmastery lesson we'll cover the neurologic examination for the headache patient.