Steven L.
Guide to the Neurologic Examination, 1st Edition
Wilkins
Neurologic Examination in Common Clinical Scenarios >Chapter 45 –
Examination of the Patient With Headache
with headache is to determine if the headache potentially represents an urgent
or lifethreatening process or is a symptom of any other structural brain,
meningeal, or systemic process (and, if not, to determine by history which
primary headache disorder is likely).
Secondary headaches are due to a structural brain lesion (e.g.,
tumor), increased intracranial pressure (e.g., tumor or hydrocephalus), a
meningeal process (e.g., meningitis or subarachnoid hemorrhage), or systemic
illness (e.g., temporal arteritis). These processes produce headache due to
irritation of pain-sensitive intracranial (e.g., meninges) or extracranial
(e.g., scalp) structures.
Primary headaches are not due to a structural brain, meningeal,
or systemic process. Common primary headaches include migraine, tension, and
cluster headache.
determining whether the headache is likely to be secondary to a serious process
that may require urgent investigation and treatment. The following are some
historical clues (summarized in Table 45-1) that are
helpful in the clinical assessment of patients with headache:
Always ask about the onset and time course of development of the
headache. Suddenness of headache onset (i.e., an explosive onset developing
over seconds) strongly suggests the possibility of aneurysmal subarachnoid (or
other intracranial) hemorrhage. Gradually progressive headaches (e.g., over
days, weeks, or months) suggest the possibility of intracranial mass lesion,
hydrocephalus, or other causes of increased intracranial pressure.
Ask about symptoms of meningeal irritation (meningismus), such as
neck stiffness or photophobia that may be seen in some patients with
subarachnoid hemorrhage or meningitis (photophobia is also a common symptom of
migraine).
Ask about any focal neurologic symptoms, such as weakness, double
vision, sensory symptoms, or gait problems, that would suggest a focal
intracranial lesion. Nausea and vomiting, although nonspecific and common in
migraine, can be a symptom of increased intracranial pressure or lesions in
the cerebellum.
In any elderly patient with new-onset headaches, consider the
possibility of temporal arteritis. Ask about discomfort or fatigue in the jaw
with chewing (jaw claudication), scalp tenderness, transient monocular vision
loss,
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constitutional symptoms, or diffuse muscle
ache (suggestive of polymyalgia rheumatica).
TABLE 45-1 Symptoms of Some
Serious Causes of Headache
Cause of Headache
Time Course
of Headache
Typical Associated Symptoms (in
Addition to
Headache)
Subarachnoid hemorrhage
Sudden onset
Neck pain and stiffness, photophobia
Meningitis
Subacute onset
Fever, neck pain and stiffness, photophobia, sometimes rash
(the presence of confusion or aphasia suggests
encephalitis)a
Intracranial hemorrhage; intraventricular hemorrhage
Sudden onset, may be progressive
Focal neurologic symptoms, nausea and vomiting, gait
dysfunction (especially with cerebellar hemorrhage)
Mass lesion
Gradually progressive
Focal neurologic symptoms, nausea and vomiting
Hydrocephalus
Gradually progressive
Nausea and vomiting, possibly gait dysfunction
Pseudotumor cerebri (idiopathic intracranial
hypertension)
Gradually progressive, or waxing and waning
Transient visual obscurations, pulsatile tinnitus,
obesity
Temporal arteritis
Waxing and waning
Monocular vision loss (transient or persistent), scalp
tenderness, jaw claudication, fevers, muscle aches
a
Meningeal processes can also cause cranial nerve or
radicular symptoms due to location of these structures within the
subarachnoid space; this most commonly occurs in chronic (e.g.,
infectious, neoplastic, or inflammatory)
meningitides.
Be suspicious for pseudotumor cerebri (idiopathic intracranial
hypertension), especially in the context of an overweight woman with
persistent headaches. Additional suggestive historical features include brief
(seconds) episodes of vision loss that mainly occur with standing (transient
visual obscurations) and pulsatile tinnitus, which represents the whooshing of
the patient’s own heartbeat.
Historical features suggestive of the most common primary
headache syndromes (migraine, tension, and cluster headaches) are summarized
in Table 45-2.
neurologic examinations. Patients with serious underlying causes of headaches
may also have normal neurologic examinations, underscoring the importance of the
neurologic history in all patients with headache. The following important clues
may be found on examination, however:
Funduscopic examination (see Chapter 11,
Funduscopic Examination) is critical in any patient with headache. The finding
of papilledema (see Fig. 11-2) suggests increased
intracranial pressure (e.g., due to mass lesions, hydrocephalus, intracranial
or subarachnoid hemorrhage, venous sinus thrombosis, or pseudotumor cerebri).
In patients with acute headache, another funduscopic finding to look for is
retinal (subhyaloid) hemorrhage (see Fig. 11-3), which
may be seen in some patients with subarachnoid hemorrhage.
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TABLE 45-2 Symptoms of Migraine,
Tension, and Cluster Headaches
Headache
Type
Headache
Location
Time Course
Additional Symptoms That May
Be
Present
Migraine
Unilateral (e.g., frontotemporal) or bilateral
Hours or days
Nausea and vomiting; photophobia and phonophobia; may prefer to
lie in dark, quiet room during attack; may occur with or without
visual aura (see Chapter 49, Examination of
the Patient with Visual Symptoms) or other transient focal motor,
sensory, or language symptoms (see Chapter
48, Examination of the Patient with Transient Focal
Neurologic Symptoms)
Tension
Bilateral; typically involves occiput, neck, or around
head
Hours or days
Usually none
Cluster
Unilateral, retroorbital; consistently on the same side for
each patient
Minutes to hours; may occur multiple times in a day; occurs in
clusters with symptom-free periods lasting months to years
Pain is excruciating; may be associated with ipsilateral eye
tearing, nasal congestion, rhinorrhea, droopy eyelid during
headache; patients often need to get up and pace during an
attack
When subarachnoid hemorrhage or meningitis is a concern, test for
nuchal rigidity by gently flexing the patient’s neck forward; significant
resistance or pain to this maneuver suggests meningismus. Also test for
meningismus by checking for Kernig’s and Brudzinski’s signs, which look for
signs of resistance to stretching of nerve roots that have been irritated due
to meningeal inflammation.
Brudzinski’s sign consists of flexion of the hips and legs when
you passively flex the patient’s neck forward.
To test for Kernig’s sign, passively flex the patient’s hip so
that the thigh is held up at approximately 90 degrees, then attempt to
passively extend (straighten) the patient’s leg at the knee, looking for
significant resistance to this maneuver and pain.
Unilateral pupillary dilation, with or without ipsilateral ptosis
or other eye movement findings consistent with a third nerve palsy (see Chapter 10, Examination of the Pupils), suggests a posterior
communicating artery aneurysm or other compressive lesion.
The finding of Horner’s syndrome (see Chapter
10, Examination of the Pupils) would suggest carotid dissection or
cluster headache (if examined during an attack).
When temporal arteritis is a consideration, palpate the temporal
arteries looking for temporal artery tenderness or induration.
Any focal findings on the general neurologic examination suggest
focal intracranial processes, but their absence does not exclude such
processes.