CHAPTER 7: The Head and Neck



Many critical structures like the sensory organs, cranial nerves (CNs), and major blood vessels originate in the head and neck. To help students integrate this complex anatomy and physiology with the skills of physical examination, this chapter follows a special format. The Health History and the Health Promotion and Counseling sections cover the “HEENT” components—Head, Eyes, Ear, Nose, and Throat—as a unit since head and neck symptoms, as well as prevention strategies, are often interconnected.

However, Anatomy and Physiology and Techniques of Examination are grouped together in five combined sections due to the close linkage between anatomic structures and function and techniques of examination, especially for the examination of the eyes (Fig. 7-1).

FIGURE 7-1 Test the complex anatomy and physiology of vision.

Test the complex anatomy and physiology of vision.

The Health History

Common or Concerning Symptoms

  • Headache
  • Change in vision: blurred vision, loss of vision, floaters, flashing lights
  • Eye pain, redness, or tearing
  • Double vision (diplopia)
  • Hearing loss, earache, ringing in the ears (tinnitus)
  • Dizziness and vertigo
  • Nosebleed (epistaxis)
  • Sore throat, hoarseness
  • Swollen glands
  • Goiter

Many symptoms of the head and neck represent common benign processes, but sometimes these symptoms reflect a serious underlying condition. Careful attention to the interview and physical examination, with a focus on features and findings that do not fit a typical benign pattern, can often distinguish a common condition of the head and neck from a serious underlying disease.

The Head

Headache is one of the most common symptoms in clinical practice, with a lifetime prevalence of 30% in the general population.[1],[2] Among types of headaches, tension headache predominates, affecting half of all individuals during their lifetime.[3] Headaches are generally classified as primary (without an identified underlying disease) or secondary (with an identified underlying disease).

However, every headache warrants careful evaluation for life-threatening secondary causes such as meningitis, subarachnoid hemorrhage, or mass lesion. Elicit a full description of every headache and its seven attributes (see p. 79). Is it unilateral or bilateral? Severe with sudden onset, like a thunderclap? Steady or throbbing? Continuous or intermittent? Is there an aura? Is the headache “typical” or is there something different?

See Tables 7-1 and 7-2 on Primary Headaches and Secondary Headaches and Cranial Neuralgias on pp. 267–269.

TABLE 7-1 Primary Headaches

 Headaches are classified as primary, without underlying pathology, or secondary, with a serious underlying cause often warranting urgent attention. Secondary headaches are more likely to occur after age 50 years with a sudden severe onset and should be ruled out before making the diagnosis of a primary headache.[3] About 90% of headaches are primary headaches and fall into four categories: tension, migraine, cluster, and chronic daily headache. The features of tension, migraine, and cluster headaches are highlighted below. Chronic daily headache is not a diagnosis, but a category containing pre-existing headaches that have been transformed into more pronounced forms of migraines, chronic tension-type headaches, and medication-overuse headaches and last more than 15 days a month for more than 3 months.[16] Risk factors include obesity; more than one headache a week; caffeine ingestion; use of headache medications >10 days a month, such as analgesics, ergots, and triptans; and sleep and mood disorders.
Tension Migraines Cluster
Process Process unclear—possibly heightened CNS pain sensitivity. Involves pericranial muscle tenderness; etiology also unclear Neuronal dysfunction, possibly of brainstem origin, involving low serotonin level, spreading cortical depression and trigeminovascular activation; types: with aura, without aura, variants Process unclear—possibly hypothalamic then trigeminoautonomic activation
Lifetime Prevalence Most common headache (40%); prevalence about 50% 10% of headaches; prevalence 18% of U.S. adults; affects ?15% of women, 6% of men <1%, more common in men.
Location Usually bilateral; may be generalized or localized to the back of the head and upper neck or to the frontotemporal area Unilateral in ?70%; bifrontal or global in ?30% Unilateral, usually behind or around the eye or temple
Quality and Severity Steady; pressing or tightening; nonthrobbing pain; mild to moderate intensity Throbbing or aching, pain, moderate to severe in intensity; preceded by an aura in up to 30% Sharp, continuous, intense; severe in intensity
  Onset Gradual Fairly rapid, reaching a peak in 1–2 hours Abrupt; peaks within minutes
  Duration 30 minutes to 7 days 4–72 hours 15 minutes to 3 hours
  Course Episodic; may be chronic Recurrent—usually monthly, but weekly in ?10%; peak incidence early to mid-adolescence Episodic, clustered in time, with several each day for 4–8 weeks and then relief for 6–12 months
Associated Symptoms Sometimes photophobia, phonophobia; scalp tenderness; nausea absent Prodrome: nausea, vomiting, photophobia, phonophobia; aura in 30%; either visual (flickering, zig-zagging lines), or motor (paresthesias of hand, arm, or face, or language dysfunction) Unilateral autonomic symptoms: lacrimation, rhinorrhea, miosis, ptosis, eyelid edema, conjunctival infection
Triggers/Factors That Aggravate or Provoke Sustained muscle tension, as in driving or typing; stress; sleep disturbances Alcohol, certain foods, or stress may provoke; also menses, high altitude; aggravated by noise and bright light During attack, sensitivity to alcohol may increase
Factors That Relieve Possibly massage, relaxation Quiet, dark room; sleep; sometimes transient relief from pressure on the involved artery

Sources: Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33:629; Lipton RB, Bigal ME, Steiner TJ Classification of primary headaches. Neurology. 2004;63:427; Sun-Edelstein C, Bigal ME, Rappoport AM.

Chronic migraine and medication overuse headache: clarifying the current International Headache Society classification criteria. Cephalalgia. 2009;29:445; Lipton RB, Stewart WF, Seymour D Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache. 2001;41:646; Fumal A, Schoenen J. Tension-type headache: current research and clinical management. Lancet Neurol. 2008;7:70; Nesbitt AD, Goadsby PJ. Cluster headache. BMJ. 2012;344:e2407.

TABLE 7-2 Secondary Headaches and Cranial Neuralgias

Type Process Location Quality and Severity Timing Associated Symptoms Factors That Aggravate or Provoke Factors That Relieve
Onset Duration Course
Secondary Headaches
Analgesic Rebound Withdrawal of medication Previous headache pattern Variable Variable Depends on prior headache pattern Depends on frequency of “mini-withdrawals” Depends on prior headache pattern Fever, carbon monoxide, hypoxia, withdrawal of caffeine, other headache triggers Depends on cause
Headaches from Eye Disorders
Errors of Refraction (farsightedness and astigmatism, but not nearsightedness) Probably the sustained contraction of the extraocular muscles, and possibly of the frontal, temporal, and occipital muscles Around and over the eyes; may radiate to the occipital area Steady, aching, dull Gradual Variable Variable Eye fatigue, “sandy” sensations in eyes, redness of conjunctiva Prolonged use of the eyes, particularly for close work Rest of the eyes
Acute Glaucoma Sudden increase in intraocular pressure (see p. 270) Pain in and around one eye Steady, aching, often severe Often rapid Variable, may depend on treatment Variable, may depend on treatment Blurred vision, nausea and vomiting; halos around lights, reddening of eye Sometimes provoked by mydriatic drops
Headache from Sinusitis Mucosal inflammation of the paranasal sinuses Usually frontal sinuses above the eyes or over the maxillary sinus Aching or throbbing, severity variable; consider possible migraine Variable Often daily several hours at a time, persisting until treatment Often daily in a repetitive pattern Local tenderness, nasal congestion, discharge, and fever May be aggravated by coughing, sneezing, or jarring the head Nasal decongestants, antibiotics
Meningitis Viral or bacterial infection of the meninges surrounding the brain and spinal cord Generalized Steady or throbbing, very severe Fairly rapid, usually <24 hours; may be sudden onset Variable, usually days Viral: usually <1 week; bacterial: persistent until treatment Fever, stiff neck, photophobia, change in mental status Immediate antibiotics until diagnosis of if bacterial or viral
Subarachnoid Hemorrhage— “Thunderclap Headache” Bleeding from a ruptured cerebral saccular aneurysm; rarely from AV malformation, mycotic aneurysm Generalized Very severe, “the worst of my life” Sudden onset; can be less than a minute Variable, usually days Varies according to presenting severity and level of consciousness; worst if initial coma Nausea, vomiting, loss of consciousness, neck pain. Possible prior neck symptoms from “sentinel leaks” Rebleeding, ? intracranial pressure, cerebral edema Subspecialty treatments
Brain Tumor Mass lesion causing displacement of or traction on pain-sensitive arteries and veins or pressure on nerves Variable, including lobes of brain, cerebellum, brainstem Aching, steady, dull pain worse on awakening the better after several hours Variable Often brief; depends on location and rate of growth Intermittent but may progress in intensity over a period of days Seizures, hemiparesis, field cuts, personality changes. Also nausea, vomiting, vision change, gait change May be aggravated by coughing, sneezing, or sudden movements of the head Subspecialty treatments
Giant Cell (Temporal) Arteritis Transmural lymphocytic vasculitis often involving multinucleated giant cells that disrupts the internal elastic lamina of large-caliber arteries Localized near the involved artery, most often the temporal artery in those > age 50, women > men (2:1 ratio) Throbbing, generalized, persistent; often severe Gradual or rapid Variable Recurrent or persistent over weeks to months Tenderness over temporal artery, adjacent scalp; fever (in ?50%), fatigue, weight loss; new headache (?60%), jaw claudication (?50%), visual loss or blindness (?15%–20%), polymyalgia rheumatica (?50%) Movement of neck and shoulders Often sterioids
Postconcussion Headache Follows mild acceleration-deceleration traumatic brain injury; may involve axonal, cerebrovascular autoregulatory, neurochemical injury Often but not always localized to the injured area Dull, aching, constant; may have features of tension and migraine headaches Within 7 days of the injury up to 3 months Weeks to up to a year Tends to diminish over time Drowsiness, poor concentration, confusion, memory loss, blurred vision, dizziness, irritability, restlessness, fatigue Mental and physical exertion, straining, stooping, emotional excitement, alcohol Rest; medication
Cranial Neuralgias
Trigeminal Neuralgia (CN V) Vascular compression of CN V, usually near entry to pons leading to focal demyelination, aberrant discharge; 10% with causative intracranial lesion Cheek, jaws, lips, or gums; trigeminal nerve divisions 2 and 3 > 1 Shock-like, stabbing, burning; severe Abrupt, paroxysmal Each jab lasts seconds but recurs at intervals of seconds or minutes May recur daily for weeks to months then resolve; can be chronic progressive Exhaustion from recurrent pain Touching certain areas of the lower face or mouth; chewing, talking, brushing teeth Medication; neurovascular decompression

Note:Blanks appear in this table when the categories are not applicable or not usually helpful in assessing the problem.

Sources: Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd ed. (beta version). Cephalalgia. 2013;33:629; Schwedt TJ, Matharu MS, Dodick DW. Thunderclap headache. Lancet Neurol. 2006;5:621; Van de Beek D, de Gans J, Spanjaard L Clinical features and prognostic factors in adults with bacterial meningitis.

N Engl J Med. 2004;351:1849; Salvarini C, Cantini F, Hunder GG. Polymyalgia rheumatica and giant cell arteritis. Lancet. 2008;372:234; Smetana GW, Shmerling RH. Does this patient have temporal arteritis? JAMA. 2002;287:92; Ropper AH, Gorson KC. Clinical practice. Concussion. N Engl J Med. 2007;356:166. American College of Physicians. Neurology—MKSAP 16. Philadelphia, 2012.

Primary headaches include migraine, tension, cluster, and chronic daily headaches; secondary headaches arise from underlying structural, systemic, or infectious causes such as meningitis or subarachnoid hemorrhage and may be life-threatening.4–6

Look for important signs (“red flags”) that warn of headaches needing prompt investigation.

The International Classification of Headache Disorders, now in its second iteration, continues to evolve.5,7–9

Headache Warning Signs

  • Progressively frequent or severe over a 3-month period
  • Sudden onset like a “thunderclap” or “the worst headache of my life”
  • New onset after age 50 years
  • Aggravated or relieved by change in position
  • Precipitated by Valsalva maneuver or exertion
  • Associated symptoms of fever, night sweats, or weight loss
  • Presence of cancer, HIV infection, or pregnancy
  • Recent head trauma
  • Change in pattern from past headaches
  • Lack of a similar headache in the past
  • Associated papilledema, neck stiffness, or focal neurologic deficits

Thunderclap headaches reaching maximal intensity over several minutes occur in 70% of patients with subarachnoid hemorrhage, and are often preceded by a sentinel leak headache from a vascular leak into the subarachnoid space.10

The three most important attributes of headache are its severity, its chronologic pattern, and its associated symptoms. Is the headache severe and of sudden onset? Does it intensify over several hours? Is it episodic? Or is it chronic or recurring? Is there a recent change in its pattern? Does the headache recur at the same time every day? What other symptoms, especially weakness or numbness in an arm or leg?

If headache is severe and of sudden onset, consider subarachnoid hemorrhage or meningitis.10

Migraine and tension headaches are episodic and tend to peak over several hours. New and persisting, progressively severe headaches raise concerns of tumor, abscess, or mass lesion.

After your usual open-ended assessment, ask the patient to point to the area of pain or discomfort.

Unilateral headache occurs in migraine and cluster headaches.4,11 Tension headaches often arise in the temporal areas; cluster headaches may be retro-orbital.

Ask about associated symptoms such as nausea and vomiting.

Nausea and vomiting are common with migraine, but also occur with brain tumors and subarachnoid hemorrhage.

Is there a prodrome of unusual feelings such as euphoria, craving for food, fatigue, or dizziness? Does the patient report an aura with neurologic symptoms, such as change in vision, numbness, or weakness?

Approximately 60% to 70% of patients with migraine have a symptom prodrome prior to onset. About a third experience a visual aura, such as spark photopsias (flashes of light), fortifications (zig-zag arcs of light), and scotomas (areas of visual loss with surrounding normal vision).

Note that, due to increased risk of ischemic stroke and cardiovascular disease, the World Health Association advises women with migraines over age 35 years and women with migraines with aura avoid use of estrogen–progestin contraceptives.[12]–[15]

Ask if coughing, sneezing, or changing the position of the head affects the headache. If head position affects the headache, ask if leaning forward or lying down increases the headache, or if lying down increases the headache.

Valsalva maneuvers and leaning forward may increase pain from acute sinusitis. Valsalva and lying down may increase pain from mass lesions due to changing intracranial pressure.

Is there any overuse of analgesics, ergotamines, or triptans?

Medication for overuse headache may cause headache if present ?15 days a month for three months and reverts to <15 days a month when the medication is discontinued.16

Ask about family history.

Genetic inheritance is present in 30% to 50% of patients with migraine.11,17