We aimed to identify the frequency of abnormal neurological examinations among patients presenting in person for headache consultation. We also aimed to determine what proportion of patients with abnormal exams have accompanying red flags in their histories and/or undergo diagnostic workup.

A key component of the initial headache evaluation is to differentiate between primary versus more serious/life-threatening secondary headache disorders. Both “red-flag” history elements and abnormal exam findings can prompt diagnostic workup to rule out a secondary headache disorder.

We conducted a retrospective review of patients presenting for in-person headache consultation to a tertiary/quaternary headache clinic from June 2022 to May 2023. We excluded patients whose exam abnormalities were consistent with known comorbidity, functional neurologic disorder, and/or non-headache disease. We calculated the proportion of patients who had abnormal neurological exams. For patients with abnormal neurological exams, the electronic medical record was reviewed for red-flag components in the history, diagnostic workup ordered, and the resulting diagnosis.

Of 1281 patients presenting for in-person headache consultation, 218 (17%) had abnormal neurological exams that were not consistent with known comorbidity, functional neurologic disorder, or non-headache disease. Of these, 203 (93%) had a red flag in their history (96 [44%] complained of a focal neurologic symptom). The remaining 15 with abnormal exams and no historical red flags comprised 1.2% of all 1281 patients. Regarding workup, 160 (73%) had neuro-imaging and 61 (28%) had laboratory studies ordered and/or requested for review, of which 13% and 8% had results concerning for pathology, respectively.

A small but notable proportion of patients presenting for in-person headache consultation had abnormalities on neurological exam. The majority of patients with abnormal exams received imaging, with a diagnostic yield higher than previously reported. However, the vast majority of patients with abnormal exams also had red flags in the history to prompt diagnostic workup.