A headache specialist makes the diagnosis not on what you think you have or what another provider previously diagnosed you with. Statistically, 50% percent of you got the wrong diagnosis which lead to a very unsatisfactory or inadequate treatment plan because it was based on a misdiagnosis (myth or fiction). So although you may be convinced that you have migraine, or sinus headaches, or occipital neuralgia, or cluster headaches, or cluster migraines, we come to our conclusions about your diagnosis from this very thorough investigation just presented to you based on published guidelines.
Our treatment plan is guided by our diagnosis. Not every drug, device or treatment plan works exactly the same for everybody. Some treatments fail due to lack of efficacy after an adequate trial at an adequate dose, some fail due to side effects, and some fail due to lack of patient education and adherence to the treatment plan. Often times, the diagnosis has to be reconsidered if there is not an adequate response to several different treatment options that are germane to the current diagnosis. If there is any concern about whether another diagnosis should be considered or further testing should be done, or if a severely disabled and chronic headache patient is not responding to conventional treatment options and alternative treatment plans or referrals are warranted, collaboration with national headache specialty colleagues is easily facilitated.
All the best and most tenured headache specialists in the country confer on difficult, perplexing and challenging-to-treat cases. Case reports are anonymously shared and collectively managed daily by colleagues participating in secure headache specialty group emails with no patient identifiers across the nation.
Although we expect your comprehensive and neurological exam to be normal with a primary headache disorder, skipping the exam completely is unacceptable. If your provider does not physically examine you, that is considered negligence and fraud. Key elements of the initial exam include:
- Vital signs - HT, WT, BMI, HR, RR, BP, Temp
- General appearance (restless or calm in a dark room)
- General exam
- Full neurologic examination
- mental status
- cranial nerves
- motor system
- muscle strength
- gait, stance and coordination, sensation, reflexes
- autonomic nervous system
- Ophthalmologic exam
- eyes and periorbital inspected for lacrimation, flushing, and conjunctival injection
- conjunctival injection should prompt investigation of the cornea and anterior chamber with a slit lamp and intraocular pressure should be measured if possible
- pupillary size and light responses, extraocular movements, and visual fields
- fundoscopic exam checking for spontaneous venous pulsations and papilledema
- patients with vision-related symptoms or eye abnormalities, visual acuity should be checked
- the conjunctiva is red, the anterior chamber and cornea are examined with a slit lamp if possible, and intraocular pressure is measured.
- Focused exam on the head and neck
- scalp examined for areas of swelling and tenderness
- ipsilateral temporal artery is palpated
- both temporomandibular joints are palpated for tenderness and crepitus
- nares inspected for purulence
- oropharynx inspected for swellings and the teeth for tenderness
- neck flexion to detect discomfort, stiffness, or both, indicating meningismus
- cervical spine palpated for tenderness