Are We Examining Enough?
The pâtisserie is quieter this afternoon. Rain softens the sound of the street outside, tracing slow patterns across the window. For a while, neither speaks.
Watson turns his cup gently between his hands.
“Last time, we agreed that calling migraine ‘primary’ shouldn’t imply that nothing can change.”
His colleague nods. “Yes, unexplained doesn’t mean unexplainable.”
Watson smiles. “Exactly. But that raises another point.”
He pauses.
“If change is sometimes possible… are we examining broadly enough to discover what might be contributing?”
When History Became Central
His colleague leans back thoughtfully. “Headache assessment today is largely history-based.”
“We take a careful narrative, apply diagnostic criteria, exclude red flags, perhaps order imaging and once migraine is diagnosed, management follows.”
“That approach has real strengths,” Watson agrees. “Migraine is, after all, a neurological disorder diagnosed primarily from clinical history.” He pauses.
“But it’s important to remember that when physical examination takes a back seat after diagnosis, we might miss important clinical signs that could guide treatment or help tailor care.”
The Curious Absence
Watson looks toward the rain-streaked glass.
“Patients frequently tell us their headache begins in the neck,” he says. “They describe stiffness, tenderness, or discomfort preceding attacks. Yet many have never had a detailed cervical examination.”
His colleague shrugs slightly. “Clinicians worry about blaming the neck too much. No one wants to give patients the wrong idea.”
“That makes sense,” Watson says. “But avoiding over-attribution doesn’t mean we should avoid looking closely.”
He pauses.
“We cannot recognise contributors we never explore.”
When Medicine Changed Direction
His colleague thinks for a moment. “Maybe physical examination became less common as imaging got better. Technology gave us reassurance. When scans looked normal, we assumed there was no structural problem.”
“And reassurance became important,” Watson adds gently. “But normal imaging tells us little about function, sensitivity, or ongoing afferent input.”
He lifts his cup.
“The nervous system reacts to signals, not just what we see on images.”
Examination as Curiosity Made Physical
“So what are we missing?” his colleague asks.
“Not answers,” Watson replies. “Questions.”
He continues:
“Examination is curiosity made physical. It allows us to explore whether peripheral input might influence a sensitised system not to replace diagnosis, but to deepen understanding.”
He adds softly:
“Migraine remains a neurological diagnosis, but how it is expressed may reflect the influences acting on a sensitised nervous system.”
His colleague nods slowly. “Especially when the trigeminocervical complex integrates cervical and trigeminal input.”
“Exactly,” Watson says. “If convergence exists biologically, it seems reasonable to explore it clinically.”
Beyond Either – Or Thinking
His colleague leans forward. “Clinicians often fear a false choice migraine or cervical headache.”
Watson smiles. “Yes. But biology rarely gives us either or problems. Different factors can exist together.”
He pauses.
“A sensitised system may amplify many inputs. Identifying one modifiable contributor does not deny the disorder; it simply broadens our options.”
What Changes Clinically?
“So examination becomes less about proving cause,” his colleague says, “and more about identifying possibilities.”
“Exactly,” Watson replies. “For clinicians, examination revives curiosity and helps identify relevant findings. For patients, it introduces new possibilities for intervention without offering false promises.”
He adds quietly, “Hope becomes practical.”
A Different Kind of Responsibility
The rain begins to ease outside.
Watson sets his cup down.
“Perhaps curiosity carries responsibility,” he says. “If change may be possible, we should look carefully for where it might begin.”
His colleague nods. “And examination becomes another way of paying attention.”
Outside, people return to the street as the clouds lift. Inside, the conversation pauses not finished, merely waiting to continue.
