Evaluation of Headache

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Physical examination

The majority of patients with headache have a completely normal physical and neurologic examination. If a complete and careful history does not point to an organic etiology, further examination is warranted in the following areas:

 Obtain blood pressure and pulse

 Listen for bruit at neck, eyes, and head for clinical signs of arteriovenous malformation

 Palpate the head, neck, and shoulder regions

 Check temporal and neck arteries

 Examine the spine and neck muscles

 A functional neurological examination is also warranted.


Potential triggers may start an attack or worsen a preexisting headache. The role of most of these headache triggers has been well established in terms of migraine but remains less clear for other headache types. (Table 2).


Patients with any of the danger signs (see above) need urgent brain imaging.

Indications for less urgent brain imaging include the following:

 Recent significant change in the pattern, frequency or severity of headaches

 Progressive worsening of headache despite appropriate therapy

 Focal neurologic signs or symptoms

 Onset of headache with exertion, cough, or sexual activity

 Orbital bruit

 Onset of headache after age 40 years.

A head CT scan (without and with contrast) is sufficient in most patients when neuroimaging is deemed necessary .

An MRI along with MRA are indicated when posterior fossa or vascular lesions are suspected.

Table - 2 Headache Triggers

Diet Stress

Alcohol Let down periods

Chocolate Times of intense activity

Aged cheese Loss or change (death, separation, divorce, job Monosodium glutamate (MSG) change)

Aspartame (Nutrasweet) Moving

Nuts Crisis

Nitrites, Nitrates

Hormones Changes of environment or habits

Menses Weather

Ovulation Travel (crossing time zones)

Hormone replacement (Progesterone) Seasons


Sensory Stimuli Schedule changes

Strong light Sleeping patterns

Flickering lights Dieting

Odors Skipping meals

Sounds, noise Irregular physical activity

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