Physical Examination and Investigations of Acute Headache

In this article, we will discuss the Physical Examination and Investigations of Acute Headache. So, let’s get started.

Physical Examination

A thorough physical and neurological examination includes:

1. The physical examination should evaluate vital signs (pulse, BP), the cardiac status, the extracranial structures (to palpate over the head and neck for detection of tender spots, to auscultate over the skull, carotid vessels for bruit, to palpate the temporal artery for pulsation) and cervical spine for pain and limitation of movements. Examine the nose and sinuses, the teeth and temporomandibular joint, the ear and throat.
2. The neurological examination:
• Mental status and level of consciousness.
• Cranial nerve examination including
optic fundi.
• Motor system examination, e.g. power, tone, reflexes, etc
• Look for neck stiffness and other signs of meningitis


Certain features in the history or examination should raise the suspicion of ominous disease warranting investigations. These danger are listed below:

Danger signals warranting testing:
1. First severe headache ever
2. Sulsacube worsening or progressive over days and weeks
3. Disturbs sleep or presents immediately after awaking
4. Abnomal neurological examination
5. Fever, nausea, vomiting or other systemic signs
6. Headache precipitated by Valsalva maneuver (cough, sneeze, bending, straining, position change, exercise and sexual activity)
7. New-onset headache in adult life (>40 years) or a significant change in a long-standing headache problem

The investigations to be done are:
1. Complete blood count. ESR and blood biochemistry
2. CSF examination: CSF examination is indicated in acute onset of headache with fever or when there are associated cranial nerve involvement. The lumbar puncture should be done after a CT scan has ruled out the possibility of raised intracranial tension.
3. Neuroimaging: The choice of MRI or CT scan will depend on the clinical suspicion, MRI or CT scan is indicated in patients of recent onset headache or headache with abnormal neurological examination (e.g. neck stiffness, focal deficits, diminished consciousness, signs of raised intracranial pressure) or progressive worsening headache, acute first severe headache, etc. An MR scan has advantage over CT scan in a patient with headache of organic cause. It helps in identification of the lesions in the brainstem and pituitary region better than CT scan. It also helps in ruling out or confirming the nature of the lesions, i.e. demyelinating, ischaemic or inflammatory disease.
4. EEG: It is not of great value in the investigation of headache.
5. Temporomandibular joint and dental evaluation for malocclusion of teeth. X-rays or MRI of TM joint is useful for displacement.

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