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11 Articles in Volume 21, Issue #1
Advanced Practice Matters with Theresa & Jeremy: Mentorship
Ask the PharmD: What is a true opioid allergy?
Behavioral Medicine: How Clinicians Can Reduce the Stigma Attached to Chronic Pain
Cardiovascular Disease and COVID-19 Infection: A Look at Long Haulers
Chronic Headache: How to Conduct a Virtual Neurological Examination
How COVID Has Changed Pain Practice and Policies
How to Conduct a Pain Evaluation Using Telemedicine
Inside the Potential of Biologics for the Treatment of Rheumatoid Arthritis
Managing Pain in Parkinson’s Disease
Spinal Cord Stimulation Shown to Improve Pain and Movement in Parkinson’s Disease
TeleRheumatology Before and During the COVID-19 Pandemic

Chronic Headache: How to Conduct a Virtual Neurological Examination

A friendly clinical guide to evaluating chronic daily headache via telemedicine.

A telemedicine evaluation of a headache patient is always interesting and important. In this article, I  briefly talk about two common types of headache – primary chronic daily headache and idiopathic intracranial hypertension headache – and review how to conduct a neurological examination as part of a real-time audio/video telehealth visit.

Chronic Headache Assessments: Translating Knowledge from In-Person Visits

To know what to look for in a televisit, it is important to first understand what you may see or find during an in-person patient visit.

When a patient has more than 15 days a month of headache for at least 3 months, they are considered to have chronic headache. It can be chronic daily headache or chronic migraine.

Let’s look at a definition. Chronic daily headache is not a diagnosis but a descriptor that encompasses several forms of frequent, daily, primary forms of headache. Primary headaches may include chronic migraine, chronic tension-type headache, hemicrania continua, and new daily persistent headache. These headaches typically last longer than 4 hours a day.

One may find musculoskeletal problems on an exam for the chronic tension-type headache. Approximately 23% of hemicrania continua patients had abnormal findings on neurological examination, which were mainly ipsilateral sensory changes such as decreased sensation of the face.1

Primary headaches with shorter periods (less than 4 hours) include chronic cluster headache, chronic paroxysmal hemicrania, hypnic headache, and primary stabbing headache. In terms of what you would expect to see during a neurological examination, the vast majority of primary headaches would be negative – except for chronic cluster headache – where you may find slight ipsilateral ptosis and/or meiosis. The most common finding on examination for chronic headache is muscle spasm, particularly a cervical myofascial pain syndrome found in chronic tension-type headache. This may also be seen in patients with chronic migraine.

Another type of headache that may be accompanied by a neurological abnormality on examination would be idiopathic intracranial hypertension. You may find papilledema or swelling of the optic disc seen in the fundi. These patients may also have visible swelling on a cerebral MRI, possibly with an empty sella or partially empty sella. In addition, they may, on an MRV, have a thrombosus in the sagittal sinus. Headache is common in this disorder although the headache may be variable and non-specific. In most cases, the headache is phenotypically migrainous or tension-type. These headaches are frequently refractory but some patients are able to obtain relief with an NSAID or rest. If refractory, medication overuse is frequently uncovered. Retrobulbar pain and eye pain may be found in some patients as well.2-5

Secondary headaches, or headaches that are secondary to and treatable when the primary issue is treated, are not within the scope of this paper.

 

How to Prepare to Give a Virtual Neurological Examination for Headache

Explain to the Patient What an Abridged Exam Means

I use the term "abridged" to indicate that several assessments needed for a complete examination are not possible, including a fundoscopic examination. Patients are typically dressed in telehealth visit, and therefore, a lower extremity sensory examination cannot be performed adequately. Muscle tone and reflex capability cannot be assessed.

Schedule the Appointment When and Where Patient Has Privacy

When performing a neurological examination via telemedicine, care must be taken from the onset, starting with scheduling. The scheduler must understand the importance of privacy and appropriate setting.

Too often, I have found myself scheduled to perform a virtual consult during a real-time audio-video visit on a patient who is driving, forcing me to reschedule for their safety, or with a patient at work and had no place to go for privacy, or with a patient who can talk privately but is unable to do an abridged neurological examination. It is up to the scheduling staff to explain that for an initial telemedicine virtual examination to work, privacy is a must, as is the ability to be in a location where an abridged neurological examination can be performed.

Suggest Caregiver Support if Needed

It is important for the patient to be alone. However, if the patient is elderly and has problems with LE strength or walking, or vertigo, you may want a family member, caregiver, or a nurse (if possible) to be present during the virtual examination to prevent a fall and to help the patient maintain safety during your examination. For example, if you ask the patient to do the concerning parts of the examination – such as a Romberg exam − and they have a fall risk, you can suggest they do it next to a couch or piece of furniture that they can grab onto for support. This may be difficult if the patient is unable to place their phone or computer in a way that you can still see them. This is where a caregiver can help.

Educate the Patient on Virtual Equipment Set-Up Before the Appointment

Possibly even more importantly, the scheduler must explain to the patient how the real-time audio-video virtual visit will be done. There are several ways to do this, using EPIC (an EMR), for instance, and other methods. I prefer Doximity. The patient must have the ability to perform the evaluation. If they have no computer and no smartphone, it is probably not going to happen. If they have a smartphone, they must know how to use the software platform (eg, Doximity). They need to have the microphone and video on their phone set to go. They need to learn how to use and respond to any texts sent to start the visit. Without this planning, most of the precious visit time may be spent on troubleshooting.

 

Taking a Patient’s History Virtually

What to Ask

While you can obtain a good portion of a patient’s history from past medical records, it is also important to take a fresh history of past and current headache in the telemedicine visit. You might ask:

  • Is there a family history of migraine?
  • What does the patient do when each type of headache occurs?
  • How often does the patient miss work secondary to headache?
  • Has the patient ever been prescribed migraine medication other than sumatriptan? If so, what were they? Did the medication help? Were there any side effects?
  • … and many more questions depending on the specific case

Mental Health Assessment is a Must

While you take the patient’s history, you should be able to determine if the patient’s cognitive ability is intact. Are they logical? Tangential? Can they start at the beginning and tell you what happened in a straightforward manner? Do they have problems answering your questions? Do you have to frequently redirect them to their history?

Taking a thorough history will also give you insight into their speech, thought processes, associations, and abnormal thought processes − hallucinations, delusions. Are they tearful, and if so, is it appropriate to what you are discussing? Is their affect appropriate? Their insight? These are things that you can test directly, but you will already have an idea when you take their history. If they appear depressed, you should check for suicidal and homicidal ideation.

If necessary, you can administer the Montreal Cognitive Assessment (MOCA) or the Mini-Mental Status Examination (MMSE). (Patients may need pencil and paper). You may even need to give the new Clinical Fibromyalgia Diagnostic Criteria if fibromyalgia is part of your differential diagnosis from the history obtained.

After you have gotten all the mental status aspects you need (see details on our sister site Psycom Pro), you can proceed with the abridged neurological exam.

Virtual Musculoskeletal and Neurological Examination

When I do a hands-on visit, I always complete a musculoskeletal and neurological examination, as well as a general examination, typically in that order. For a virtual visit, I would start with the cervical range of motion: Does the patient have meningeal signs? Is there evidence of a cervical myofascial pain syndrome? This is important, particularly if tension-type headaches are part of your differential diagnosis.

Then, I move on to a cranial nerve examination. As noted, a fundoscopic examination is not possible in a telemedicine setting. If you are concerned about idiopathic intracranial hypertension (pseudotumor cerebri) and need to know if the patient has papilledema – especially if they complain of visual changes or transient visual obscurations (which would be associated with papilledema) – you should do what you can to have them seen at an urgent care center or ED, or if possible quickly, by a neuro-ophthalmologist.

In terms of conducting an abridged virtual neurological examination – performed with the patient’s help – it would be realistic to expect that migraine would not show anything on interictal examination except, possibly, cervical muscle spasm. Keep in mind that many individuals with migraine have a history of neck pain too, but you may find musculoskeletal abnormalities secondary to the patient’s chronic tension-type headache.

Some neurological tests you can have the patient perform on screen:

  • Ask them to cover each eye and report what they see with the other eye. Are there changes in the visual field? Peripheral or central? Any significant changes should be evaluated urgently by an ophthalmologist or, at your discretion, in an ED. In patients with visual changes, I would recommend more of an examination.
  • Look for extraocular movements and nystagmus.
  • Ask the patient to use both index fingers to lightly stroke each fifth cranial nerve division. Do they feel the same? If a patient has a diagnosis of trigeminal neuralgia, are there trigger zones? Where? Are there dysesthesias to touch? You can even ask the patient to get an ice cube and touch the bilateral V1-V3 distributions, for example, and see if the cold is the same or is it different on either side. You would, of course, do this throughout the face and even upper and distal lower extremities (if it is too awkward for the patient to test their upper LEs).
  • Ask the patient to use their index fingers to touch both UEs and see if it feels the same. Again, it is more difficult to do this in a dressed patient for the LEs, as it may be awkward to ask them to change clothes (out of your sight, of course), and impossible if the patient is in a private room at work.
  • Ask them to close their eyes tightly, show you a big smile, show you their teeth, and raise their eyebrows to test for facial muscle strength.
  • Ask them to open their jaw wide and look for jaw deviation.
  • For cranial nerve VIII, you can see if their hearing is intact to voice and show the patients how to rub their four fingers against their thumb and check their ability to hear finger rubbing.
  • Is there dysarthria (CN, IX, X)? You can look, if the light is good enough, for palate elevation. You can ask the patient to shrug their shoulders for cranial nerve XI and stick out their tongue to look for atrophy or fasciculations (CN, XII).
  • Test for rapid alternating movements using the UEs. Look at finger tapping as well as thumb touching each finger – is it done smoothly? Can the patient do an arm roll?
  • In some cases, and if the patient is comfortable, you may wish to ask a present caregiver to take a pen or pencil and scratch the bottom of the patient’s foot, moving it up and across the foot under the toes to look for a Babinski reflex. I typically do not do that as a false positive or negative can be problematic, and you would already have an idea regarding what you will see
  • Look for a tremor. Is there bradykinesia? Is there a petit pas gait? Masked faces? Again, there are many things you can examine, but in the typical headache patient, these things should not be expected unless there is a history of stroke or neurosurgical procedure or neurodegenerative disorder.
  • For strength, when you ask a patient to do a Romberg, you can evaluate for pronator drift. You can ask the patient to cross their arms. Then ask them to embrace themselves, which would have them place their hands and arms even further back. Can they do this symmetrically? Do you see any signs of UE contracture or spasticity?
  • For the Romberg test, the phone or computer that the patient is using for video must be moved so you can see the patient – from the top of their head to the bottom of their feet – with them standing 10 to 15 feet away (if safe). Observe gait, station, heel, toe, and tandem gait. Can they stand on one foot? Can they do squats or even a pushup if you are worried about strength. This will allow you to look for bilateral symmetry, spastic gait, and contractures. If all appears normal, you should have a good, general evaluation for strength. 
  • See case example below

             

 

What You Will Likely Miss in a Telemedicine Exam

Of note, visual field testing – as well as line bisection and visual field extinction – are difficult to do remotely. One major issue is the video medium that the patient is seeing. Another is the awkwardness of attempting the testing itself (ie, trying to have patients read sentences may be difficult). If they cannot, is there a visual field defect or a problem with the video they are using? One thing you can do is to look for pupillary size changes from a flashlight or having them close their eyes tightly and then open them, with their eyes close to the video device so you can check for accommodation.

A motor examination can be looked at in several ways. As patients are dressed when you talk to them, it may be awkward to have them remove their clothing to look at muscle bulk and look for atrophy. However, I typically do not do this.

It is also impossible to test for reflexes, muscle tone, specific small muscle strength, or, as noted, to do a fundoscopic examination.

For additional provider tips, see:

Practical Takeaways

  • When examining relatively young persons for the complaint of headache, your abridged neurological exam will likely be negative. One exception would be cervical myofascial spasm/pain associated with chronic tension-type headache.
  • For migraine, expect a negative examination most often, but keep in mind that individuals with migraine may also have cervical myofascial issues. In abnormal cases, migraine with a hemiplegic or retinal aura may present. Alternatively, during the typical migrainous aura, which lasts between 5 and 60 minutes before the migraine headache, you may find the patient experiences visual, sensory, speech changes (eg, expressive or receptive aphasia), or cognitive changes.
  • With cluster headache patients, you may see ptosis and/or meiosis. Trigeminal Automonic Cephalalgia’s (TACs) can have subtle changes.
  • To conduct an effective abridged neurological examination, you want to be sure that it is done to the best of your and the patient’s ability. Obtaining a thorough history – including any comorbid mental health issues – is necessary to give you the best chance of developing a correct diagnosis and treatment plan for your headache patients.
Last updated on: January 5, 2021
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