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:
• 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.
HEADACHE TRIGGERS
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).
INDICATIONS FOR IMAGING STUDIES
Patients with any of the danger signs (see above) need urgent brain imaging.
Indications for less urgent brain imaging include the following:
• 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
Altitude
Sensory Stimuli Schedule changes
Strong light Sleeping patterns
Flickering lights Dieting
Odors Skipping meals
Sounds, noise Irregular physical activity
