Migraine physical examination

The majority of patients with headaches complaints have a normal physical and neurological examination. Signs suggestive of a serious cause of headache, such as systemic symptoms, focal neurological signs, seizures or impairment of the level of consciousness should be ruled out.

The patient appear with a headache.

• Tachycardia/ bradycardia
• Hypertension/ hypotension

• Conjunctival injection may be present

• Horner’s syndrome ^[1] may be present
• Adie type pupil ^[2] may be present

• Cranial/ cervical muscle tenderness may be present
• Listen for bruit at neck and head for clinical sights of arteriovenous malformation.

Focal neurological signs that occur with the headache and persist temporarily after the pain resolves suggest a migraine variant:

• Hemiplegic migraine: unilateral paralysis or weakness^[3]

• Basilar type migraine: dysarthria, vertigo, tinnitus, diplopia, ataxia, decreased level of consciousness, simultaneous paresthesias^[4]

• Ophthalmoplegic migraine: Third nerve palsy, with ocular muscle paralysis and ptosis, including or sparing the pupillary response^[5]

Signs that suggest a more serious cause of headache:

• Systemic symptoms (ie. myalgia, fever, weight loss, scalp tenderness, jaw claudication) and
• Focal neurological signs or
• Confusion, seizures or
• Impairment of level of consciousness