Revisiting the headache-focused neuro exam

My most viewed blog post was the one about the headache-focused neurologic examination. I posted it 4 years ago, February 2019. Because of its popularity, I thought it would be a good idea to take a look and update it where needed.

The most important part of any office visit is the conversation between provider, patient and family. The more time you spend getting to know the patient, observe the family dynamic, and get a thorough history, the more valuable the visit is for all. You can tease out the real issues and concerns just by taking time with them.

In addition, I always do a mostly neurological focused physical exam.  There are certain findings which are common among patients with headaches, some notable particularly for migraine. I will review a typical neuro exam and share some clinical pearls in this post.

The nervous system is a complex network of fibers, woven throughout the entire body and responsible for both simple and complicated human functions. The neurologic exam is divided into several components, focusing on different parts of the nervous system.  These components include: mental status, cranial nerves, motor system, sensory system, deep tendon reflexes, coordination and the cerebellum, and gait. Much of the exam can be done during the visit, prior to the formal exam, by interacting, observing and listening to the patient.

Mental status: This part of the neuro exam is done throughout the visit. The patient will answer questions about school and life, general functioning, any social concerns.  You assess whether they are dressed appropriately, have good hygiene and assess their mood and interactions with whoever accompanies them to the visit. Attention also needs to be paid to achievement of appropriate developmental milestones. In general, the child or teen with headache is alert and engaged, conversant about a variety of topics, and communicating in an age-appropriate way, unless there is an underlying developmental delay or challenge, such as autism.

• One finding to think about is any side effect of medications; many of our daily headache preventive medications can cause mental clouding, even in the smallest of doses. This is a little tricky to ascertain since most teens do not know what mental clouding means. I usually ask if they are having any trouble with memory, or unexpected school difficulties, or just not feeling as sharp as usual.  Often they do not recognize this until I ask and are relieved to know it could be a medication side effect.
• Another important finding is their mental health status. Are they reporting any anxiety or depression, cutting, suicidal ideation, school avoidance? Are worries getting in their way at school, at home or with friends? We know there is a connection between headache and mental health challenges and need to address what they report and what we perceive.
• In addition, reports from the parent or family member also let us know how they are doing. Have they been more irritable, less engaged with activities and friends, staying in their room a lot? An observant parent can lend clues to how your patient is coping with both headache and life in general.

Cranial nerves: Assessing the cranial nerves is done both formally and informally during the visit.  You assess their hearing and speech, watch their facial and head movements.  On the formal exam, you assess the function of the 12 cranial nerves by having them do a few maneuvers, checking out their eyes with the ophthalmoscope. A few assessments have implications for headache, such as:

• Assessing any scalp sensitivity: this may indicate any occipital nerve irritation, or central sensitization often seen in chronic headache/migraine. It would not be uncommon for a patient with chronic headache to report discomfort having their scalp even lightly palpated and that it hurts to brush their hair (central sensitization). If their occiput is painful, there may be occipital neuralgia related to tension-type headaches.
• Assessing trigeminal distribution, making note of an increased level of sensitivity (prickly, tickly or discomfort) as you move laterally across cheek to above their ears with a pointy object.  This is documented as sensitivity within the distribution of the nucleus caudalis, and a common finding in migraine.
• Assessing eye movements, being especially aware of any nystagmus or convergence insufficiency.  Inability to cross the eyes can have a negative effect, especially with balance or reading, leading to eye fatigue and blurry vision. Convergence insufficiency can be treated by specific eye exercises/therapy or glasses. This tends to be more bothersome in high school/college age students, mainly because they have a lot of reading to do.
• Assessing facial movements for symmetry and differences, assessing tongue movement (dysarthria, dysphagia), which can indicate developmental anomalies.
• Assessing for facial pain within trigeminal nerve distribution, leading to a diagnosis of trigeminal neuralgia or atypical facial pain.
• Fundoscopic eye exam: looking for clear optic disk margins, intact light reflexes, normal venous pulsations, assessing for papilledema indicating increased ICP.
• Assessing forehead and brow movement can demonstrate the level of Botox wear off. Minimal movement might indicate the time between Botox procedures can be increased.

Motor system: You assess the motor system by looking at the strength and tone of muscle groups, looking for asymmetry, atrophy, abnormal movements, or pain with movement, and any baseline changes over time.

• Assessing for any jaw asymmetry, jaw clicking or discomfort by palpating the TMJ. This can indicate teeth grinding or clenching related to anxiety or TMJ dysfunction which can be a source of headache.
• Assessing general motor function for what is developmentally appropriate, as well as what can be expected of certain underlying conditions, such as cerebral palsy.
• Certain brain vascular abnormalities, such as AVM, could lead to extremity weakness and/or atrophy and cause headache.
• Palpating the neck/upper back area for tightness or tenderness can indicate a pain source/trigger point for tension-type headache, which might improve with local anesthetic trigger point injections.
• Observing neck movement (flex forward, bend backward) can uncover any meningeal irritation; having the patient bend forward (L’hermitte sign) can reveal any spinal column irritation. Both findings are concerning and require further investigation.

Sensory system: Sensation relies on impulses from stimulation of receptors in all parts of the body and sent to the central nervous system. When you assess the sensory system, you are looking for any abnormal sensation, by checking temperature, vibration, pressure and position. Differences in sensation can be a part of the neurologic system for the patient, not necessarily pathologic.

• Patients with migraine can have differences in sensation at baseline. They might feel cold, vibration, pressure, or prickliness more acutely or prominently on one side of the body than the other. This is part of being a migraineur, especially in pediatrics.
• Sensitivity felt as pain to light touch (allodynia) anywhere in the body is an abnormal finding and can indicate possible nerve compression or injury, or in the scalp, central sensitization.
• Tingling or the feeling of ‘pins and needles’ can be associated with small fiber neuralgia (ANS sensitivity common among people with headaches/migraines) or as a side effect of medication, such as topiramate. Both should be looked at more closely.

Deep tendon reflexes: Involuntary responses to a specific stimulus are reflexes. Alterations can be the first indicator of neurologic dysfunction. Unless there is an underlying condition which impedes function, patients with headache should have intact reflexes.

• Often patients with chronic headache (migraine, NDPH) will be hyper-reflexive (get out of the way to avoid getting kicked).  This is generally a manifestation of a sensitive autonomic nervous system, very common among these patients.
• Patients who are hypo-reflexive could have an underlying thyroid insufficiency, so ruling that out would be worthwhile.  Also hypothyroid can be associated with migraine.
• Learn the distraction strategies that can help elicit reflexes. Patients often enjoy doing this and think it is a magic trick. You get to assess their reflexes.

Coordination and the cerebellum: The cerebellum controls voluntary movement and motor coordination. Testing coordination provides information about cerebellar functioning and includes: finger-to-nose testing, alternate hand flipping, finger tapping, heel-to-shin movement.

• Assessing for coordination in younger children is also an assessment of development; young children often have some difficulty with the smoothness of their hand flipping or finger-to-nose. Patients with headache do not generally show abnormality in this area.
• Hopping is an easy way to assess coordination and balance, and fun to do.
• Standing on one leg also tests balance; one side is often more wobbly in the average person.
• The Romberg maneuver is a test used to assess for balance, and is useful when assessing concussion, sitting and standing. The premise is that a person requires at least two of the three following senses to maintain balance: proprioception; vestibular function; and vision. After mild head trauma, symptoms of unbalance and unsteadiness often last longer in patients with an underlying headache disorder than for people without headaches.

Gait: Assessing gait is the assessment of a very intricate physiological process involving motor, sensory, and balance systems. It can be a window into any challenges in the nervous system. There are normal developmental differences in the gait of our young children and teenagers, with/without headaches, and in the gait of those who are recovering from concussion. Observing gait involves watching them walk, run and doing heel-toe walking. Much of this can be done just escorting them down the hall to the exam room.

• Assessing heel-toe walking in the concussion patient provides clues to their recovery. Most patients immediately post-concussion have difficulty with this, improving over time. Can they do heel-toe walking? If so, perhaps they can return to their usual activity. If not, they are not quite ready.
• Watching your patient run in the hallway is a good assessment of whether or not they are ready to embrace a multidisciplinary approach to functioning. If they are able to tolerate a brief run, they are ready to be more physically active and be successful increasing their aerobic activity.

These are the basics involved in a headache-focused neurologic exam, and some specific findings often seen in a patient with headaches. With the information provided, hopefully you will pick up on any unusual findings, which are not unusual for the headache