The examination will reflect the suspected diagnosis, particularly in the case of local disease of the oral cavity. A good light and expertise in examining the oral tissues is necessary. The head and neck should be carefully examined. Assess tenderness over the temporal arteries as well tenderness in the scalp, neck muscles and muscles of mastication. Examination of patients with temporomandibular disorders (TMD) involves the application of pressure to a variety of specific anatomical sites to see if they are tender (trigger points). The range of movements of the mandible is then evaluated in vertical opening, protrusive and lateral positions. A brief but thorough neurological examination, especially of the cranial nerves, should be undertaken, particularly if the diagnosis is uncertain or intracranial pathology is suspected. Fundoscopy is mandatory in all patients presenting with headache. Examination of the cranial nerves is particularly important for orofacial pain. General examination is indicated if headaches are considered secondary to systemic disease.

There is no indication for investigations of primary headaches and they should be undertaken only if a secondary headache is suspected. If autoimmune disorders are suspected then blood tests may be indicated. Non-contrast computed tomography (CT) with axial and coronal sections is indicated for sinusitis, rhinogenic causes of pain or if malignancy is suspected. Magnetic resonance imaging (MRI) is useful to evaluate internal derangement in TMD. MRI and/or magnetic resonance angiography (MRA) can evaluate intracranial pathology. Special thin cut MRIs of the posterior fossa are needed to identify trigeminal nerve root compressions.

Patients’ beliefs are fundamental and must be clarified before treatment is initiated (Box 9.3). Severity of disease, impact on quality of life, insight and chronicity will impact on adherence to treatment as well as how the family views the condition (Box 9.4). The approach must, therefore, be a biopsychosocial one.