II. General

  1. Neurologic deficit suggests Organic Headache
  2. Organic Headache is unlikely without neurologic deficit

III. Exam: Key Neurologic Assessment

  1. Complete Neurologic Examination
    1. Motor Exam (Hemiparesis)
    2. Sensory Exam (especially Trigeminal Nerve sensation)
    3. Cranial Nerve exam
    4. Deep Tendon Reflexes
    5. Coordination and gait (e.g. Ataxia)
    6. Signs of Meningeal Irritation
      1. Nuchal Rigidity on Passive neck flexion
  2. Altered Level of Consciousness
    1. Causes of Focal neurologic deficits
      1. Cerebrovascular Accident
    2. Causes of Non-focal neurologic deficits
      1. Meningitis
      2. Encephalitis
      3. Subarachnoid Hemorrhage
      4. Intracranial Hypertension
      5. Anoxia

IV. Exam: Other key points

  1. Vascular examination
    1. Carotid Bruit
    2. Temporal artery bruit, firmness, tenderness or pain
  2. Head and Neck Exam
    1. Sinus tenderness
    2. Neck range of motion
    3. Trapezius muscle or Sternocleidomastoid muscle tenderness or spasm
  3. Eye Examination
    1. Pupil reaction
    2. Visual Fields
    3. Intraocular Pressure (Narrow Angle Glaucoma)
    4. Abnormal eye movements (e.g. Nystagmus)
    5. Funduscopic Examination (e.g. Papilledema)
  4. Skin Findings suggestive of intracranial neoplasm
    1. Neurofibromatosis
    2. Tuberous Sclerosis
  5. Vital Signs
    1. Head Circumference in children
    2. Tachycardia
      1. Intracranial lesion (see list below)
    3. Hypertension
      1. Hypertensive Headache
      2. Intracranial Lesion
        1. Hematoma
        2. Subarachnoid Hemorrhage
    4. Fever
      1. Meningitis
      2. Encephalitis
      3. Viral Syndrome
      4. Temporal Arteritis
      5. Acute Sinusitis

V. References

  1. Cutrer in Goldman (2000) Cecil Medicine, p. 2066
  2. Duman in Friedman (1991) Medical Diagnosis, p. 392-3
  3. Henry in Marx (2002) Rosen's Emergency Medicine, p. 152
  4. Pruitt in Goroll (2000) Primary Care Medicine, p. 931-9

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