Cervicogenic and Tension-Type Headaches Care Pathway

7. Physical Examination

 

Overview: A comprehensive physical examination considers the biopsychosocial aspects of a patient’s condition, cultural sensitivity, informed consent, and the patient’s overall comfort. The selection and scope of assessments should be tailored to the individual clinical encounter, with a focus on increasing confidence in primary diagnostic considerations and refining differential diagnoses. This section provides an inventory of assessments rather than a prescriptive algorithm, allowing clinicians to choose appropriate measures based on the unique presentation and needs of each patient.

 

Additional Details for Selected Components:

• Neurological Examination: Record clinical findings for each:

• Motor strength testing: E.g., C5: Shoulder abduction:  L 3/5, R 5/5.

• Sensory testing: E.g., " Patient reports that they perceive the same for sharp, light, and vibration for C5, C6, C7, C8 and T1." "Patient reports a loss of perception of sharp and light for C7 on the right with all other sensations intact."

• Reflex testing: E.g., C5: R 2/4, L 3/4

• Upper motor neuron signs: E.g., "UMN signs: Muscle tone (increased/normal), Hyperreflexia (yes/no), Babinski sign (positive/negative), Clonus (yes/no)."

• Lower motor neuron signs: E.g., "LMN signs: Atrophy (yes/no), Fasciculations (yes/no), Muscle tone (reduced/normal), Function loss (symmetrical/asymmetrical)."

 

Cranial Nerve Tests:

• CN I (Olfactory): Sense of smell.

  • Record Findings: E.g., "Patient correctly identifies coffee and peppermint scents with both nostrils."

• CN II (Optic): Visual acuity and visual fields.

  • Record Findings: E.g., "Visual acuity 20/20 bilaterally, visual fields full to confrontation."

• CN III, IV, VI (Oculomotor, Trochlear, Abducens): Eye movements, pupil response.

  • Record Findings: E.g., "Extraocular movements intact, pupils equal, round, reactive to light and accommodation (PERRLA)."

• CN V (Trigeminal): Facial sensation, mastication muscles.

  • Record Findings: E.g., "Facial sensation intact in all three branches, masseter and temporalis muscles strong bilaterally."

• CN VII (Facial): Facial expressions (smile, frown), taste (anterior 2/3 of the tongue).

  • Record Findings: E.g., "Symmetrical facial movements, patient can smile, frown, and raise eyebrows; taste test not performed."

• CN VIII (Vestibulocochlear): Hearing and balance.

  • Record Findings: E.g., "Whisper test positive bilaterally, Romberg test negative."

• CN IX, X (Glossopharyngeal, Vagus): Gag reflex, palate elevation, swallowing.

  • Record Findings: E.g., "Gag reflex intact, palate elevates symmetrically, no difficulty swallowing."

• CN XI (Accessory): Shoulder shrug, head rotation.

  • Record Findings: E.g., "Shoulder shrug strong, and symmetrical head rotation against resistance normal."

• CN XII (Hypoglossal): Tongue movements (deviation).

  • Record Findings: E.g., "Tongue midline without deviation, moves normally in all directions."

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Special/Orthopedic Tests: 

• Select tests to use alongside a comprehensive clinical examination; the validity and reliability of these tests vary.

• Document: Test side, results (positive/negative), and responses (e.g., “Spurling’s R(-), L(+) patient reports pain to left arm”).  

 

Tests for Cervicogenic Headache:

1. Cervical Flexion-Rotation Test: Positive test: reproduces or exacerbates headache symptoms.

2. Myofascial Trigger Point Examination: Localized pain and referred head pain upon compression of trigger points.

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Tests for Meningitis:

1. Kerning’s Sign: Positive test: Resistance and pain in the neck and back when attempting to straighten a flexed knee from a 90° hip flexion position.

2. Brudzinski’s Sign: Positive test: Involuntary flexion of the hips and knees when the neck is flexed forward.
    

Advanced Diagnostics:
Imaging: Generally not recommended within the first six weeks unless red flags are present, to avoid unnecessary radiation exposure, overdiagnosis, and costs. ​Currently, there is insufficient evidence that routine imaging improves patient outcomes. Discuss the benefits and risks of imaging with patients, educating them on the role of imaging and reasons for deferring it initially when applicable. Imaging used in specific contexts should be discussed through shared decision-making (e.g.,  persistent pain and functional limitations).