Headache Classification and Management — MCQs

10 questions

A 35-year-old woman presents with a persistent, throbbing headache on one side of her head, associated with nausea and sensitivity to light. What is the most likely diagnosis?

Drugs used in management of migraine include the following except?

Signs of increased intracranial tension are all except:

A 45-year-old man presents with a daily headache over the past 3 weeks. Each attack lasts about an hour and awakens the patient from sleep. It is associated tearing and reddening of his right eye. The pain is deep, excruciating, and limited to the right side of the head. The neurologic examination is normal. The most likely diagnosis:

Commonest cause of thunderclap headache:

All of the following are types of Primary headache except:

A 65-year-old patient presents with severe headache, temporal artery tenderness, and decreased pulse. What is the most likely diagnosis?

A 32-year-old woman presents to you for evaluation of headache. The headaches began at age 18, were initially unilateral and worse around the time of her menses. Initially the use of triptans two or three times a month would provide complete relief. Over the past several years, however, the headaches have become more frequent and severe. Triptans provide only partial relief; the patient requires a combination of acetaminophen, caffeine, and butalbital to achieve some improvement. Prophylactic medications including beta-blockers, tricyclics, and topiramate have been unsuccessful in preventing the headaches, and she has been to the emergency room three times over the past 2 weeks for a "pain shot." The general physical examination is unremarkable. Her funduscopic examination shows no evidence of papilledema, and a careful neurological examination is likewise normal. What is the most likely explanation for her headache syndrome?

Consider the following clinical features : 1. Raised ICP 2. Seizures 3. Focal deficit 4. Headache Which of the above clinical features are related to most brain tumours?

Q10

Which of the following is not used in the management of post-dural headache?

Headache Classification and Management Indian Medical PG Practice Questions and MCQs

Question 1: A 35-year-old woman presents with a persistent, throbbing headache on one side of her head, associated with nausea and sensitivity to light. What is the most likely diagnosis?

A. Cluster headache
B. Tension headache
C. Sinusitis
D. Migraine (Correct Answer)

Explanation: ***Migraine*** - Migraines are characterized by **unilateral, throbbing headaches** associated with **nausea, vomiting**, and **sensitivity to light (photophobia)** and sound (phonophobia) [1]. - The patient's presentation perfectly aligns with the classic symptoms of a migraine attack [1]. *Cluster headache* - Cluster headaches are characterized by **severe, unilateral pain**, but they are typically **periorbital or temporal** and associated with **autonomic symptoms** such as lacrimation, rhinorrhea, ptosis, and miosis [1]. - Unlike migraines, they tend to occur in clusters over several weeks or months, followed by a period of remission. *Tension headache* - Tension headaches are usually described as a **dull, aching pain** or a **tight band around the head**, often bilateral, and are typically **not associated with nausea, vomiting, or photophobia** [1]. - They are generally less severe and do not worsen with physical activity. *Sinusitis* - Sinusitis can cause headache, but it is typically accompanied by **facial pressure or pain**, nasal congestion, colored discharge, and sometimes fever. - The pain is usually localized to the frontal, maxillary, or ethmoid sinuses and is not typically throbbing or associated with photophobia and nausea to the extent seen in migraines.

Question 2: Drugs used in management of migraine include the following except?

A. Topiramate
B. Valproate
C. Ethosuximide (Correct Answer)
D. Verapamil

Explanation: ***Ethosuximide*** - **Ethosuximide** is an anti-epileptic drug primarily used to treat **absence seizures** by blocking T-type calcium channels [1]. - It has no established role in the **acute** or **prophylactic** management of migraine headaches. *Topiramate* - **Topiramate** is an anti-epileptic drug that is also approved for **migraine prophylaxis**. - Its mechanism of action in migraine includes modulating **GABA receptors**, blocking **voltage-sensitive sodium channels**, and inhibiting **carbonic anhydrase** [2]. *Valproate* - **Valproate** (valproic acid) is an anti-epileptic drug and mood stabilizer commonly used for **migraine prevention**. - Its migraine prophylactic effect is believed to involve increasing **GABA levels** and modulating **neurotransmitter release** [1]. *Verapamil* - **Verapamil** is a **calcium channel blocker** sometimes used off-label for **migraine prophylaxis**, particularly in cases of difficult-to-treat migraines or specific subtypes like **hemiplegic migraine**. - It works by reducing cerebral vasospasm and stabilizing neuronal membranes.

Question 3: Signs of increased intracranial tension are all except:

A. Headache
B. Seizures
C. Papilledema
D. Tachycardia (Correct Answer)

Explanation: ***Tachycardia*** - **Tachycardia** is generally *not* a sign of increased intracranial pressure (ICP); rather, **bradycardia** (Cushing's reflex) is a classic finding. - While other systemic responses may occur, a direct, consistent increase in heart rate due to elevated ICP is uncommon. *Papilledema* - **Papilledema** is a swelling of the **optic disc** due to increased ICP, a critical diagnostic sign [1]. - The increased pressure impedes venous return from the retina, causing the optic nerve head to bulge. *Headache* - **Headache** is a common and often early symptom of increased ICP due to the stretching of pain-sensitive meningeal and vascular structures [1]. - It is typically described as a dull, throbbing pain, often worse in the morning or with straining. *Seizures* - **Seizures** can result from increased ICP as the pressure on brain tissue can lead to electrical instability and abnormal neuronal discharge [2]. - This symptom indicates significant cortical irritation or dysfunction caused by the elevated pressure.

Question 4: A 45-year-old man presents with a daily headache over the past 3 weeks. Each attack lasts about an hour and awakens the patient from sleep. It is associated tearing and reddening of his right eye. The pain is deep, excruciating, and limited to the right side of the head. The neurologic examination is normal. The most likely diagnosis:

A. Tension headache
B. Cluster headache (Correct Answer)
C. Migraine headache
D. Brain tumor

Explanation: **Cluster headache** - **Cluster headaches** are characterized by severe, unilateral head pain, often around the eye or temple, accompanied by **autonomic symptoms** such as **tearing**, **conjunctival injection** (redness of the eye), miosis, ptosis, and rhinorrhea (runny nose) on the affected side. - These attacks typically last between 15 minutes and 3 hours, occur in clusters over weeks or months, and frequently **awaken the patient from sleep**. *Tension headache* - **Tension headaches** are usually described as a bilateral "band-like" or pressing pain, typically mild to moderate in intensity. - They are generally not associated with neurological symptoms or severe autonomic features like tearing or eye redness. *Migraine headache* - **Migraine headaches** are often unilateral and throbbing, associated with **nausea, vomiting**, and **photophobia** (light sensitivity) or **phonophobia** (sound sensitivity). - While some autonomic symptoms can occur, the dramatic and consistent presentation of tearing and conjunctival injection during attacks, along with the short duration and sleep correlation, are more typical of cluster headaches. *Brain tumor* - A **brain tumor** could cause headache, but usually the pain is constant, progressive, and often associated with other focal neurological deficits like weakness, sensory changes, or seizures, which are absent in this case. - The **episodic nature** and distinct autonomic features of the headache in this patient make a primary headache disorder far more likely than a brain tumor.

Question 5: Commonest cause of thunderclap headache:

A. Basilar migraine
B. Extradural hemorrhage
C. Subdural hemorrhage
D. Aneursymal SAH (Correct Answer)

Explanation: ***Aneursymal SAH*** - An **aneurysmal subarachnoid hemorrhage (SAH)** is the most common and often life-threatening cause of a **thunderclap headache**, characterized by a sudden, severe headache reaching maximum intensity within one minute [1]. - The sudden rupture of a cerebral aneurysm leads to blood spilling into the subarachnoid space, causing a rapid increase in intracranial pressure and meningeal irritation. *Basilar migraine* - While basilar migraine can cause severe headaches, it typically presents with neurological symptoms like **vertigo**, **ataxia**, and **diplopia** preceding the headache phase, and its onset is usually less abrupt than a thunderclap headache. - Basilar migraines usually have a **recurrent pattern** and are associated with a history of similar migraine episodes, unlike the abrupt, singular nature of an SAH-related thunderclap headache. *Extradural hemorrhage* - An **extradural (epidural) hemorrhage** is usually caused by **head trauma** and often presents with a **lucid interval** followed by a progressive neurological decline, rather than an immediate thunderclap headache [2]. - It involves bleeding between the **dura mater** and the skull, which typically develops more slowly than the catastrophic onset of an SAH. *Subdural hemorrhage* - A **subdural hemorrhage** is usually caused by **venous bleeding** and can be acute, subacute, or chronic, often presenting with a gradual onset of symptoms like headache, confusion, and neurological deficits [2]. - While an acute subdural hematoma can be severe, its headache is generally not as instantaneously explosive or universally described as a thunderclap as that seen with SAH.

Question 6: All of the following are types of Primary headache except:

A. Migraine
B. Tension
C. Cluster
D. Temporal arteritis (Correct Answer)

Explanation: ***Temporal arteritis*** - **Temporal arteritis** is a **secondary headache** caused by inflammation of the **temporal arteries**, not a primary headache type [1]. - It is often associated with symptoms like **jaw claudication**, **scalp tenderness**, and is more common in elderly individuals. *Migraine* - **Migraine** is a common type of **primary headache**, characterized by moderate to severe pain, often unilateral and pulsating [1]. - It can be accompanied by symptoms like **nausea, vomiting**, and sensitivity to light and sound [1]. *Tension* - **Tension-type headache** is the most common type of **primary headache**, typically described as a mild to moderate, bilateral, pressing or tightening pain [1]. - It usually lacks associated symptoms like nausea or vomiting, which differentiates it from migraine. *Cluster* - **Cluster headache** is a severe form of **primary headache**, known for its excruciating unilateral pain, often around the eye or temple [1]. - It is characterized by specific autonomic symptoms on the affected side, such as **lacrimation, rhinorrhea, and ptosis** [1].

Question 7: A 65-year-old patient presents with severe headache, temporal artery tenderness, and decreased pulse. What is the most likely diagnosis?

A. Giant cell arteritis (Correct Answer)
B. Wegener's granulomatosis
C. Microscopic polyangiitis
D. Takayasu arteritis

Explanation: ***Giant cell arteritis*** - This presentation with **severe headache**, **temporal artery tenderness**, and a **decreased pulse** in a 65-year-old patient is highly classic for giant cell arteritis (GCA). GCA characteristically affects **medium and large arteries**, often the **temporal artery**. - **Decreased pulse** can indicate involvement of other large vessels, such as the subclavian artery, which can occur in GCA. Urgent diagnosis and treatment are crucial due to the risk of **permanent vision loss** [1]. *Wegener's granulomatosis* - This condition (**granulomatosis with polyangiitis**) is characterized by **upper and lower respiratory tract granulomatous inflammation**, **glomerulonephritis**, and small vessel vasculitis. - While it can manifest with systemic symptoms, **temporal artery tenderness** and a **decreased pulse** are not primary features of Wegener's. *Microscopic polyangiitis* - This is a **small vessel vasculitis** that primarily affects capillaries, venules, and arterioles. - It typically presents with **glomerulonephritis** and **pulmonary capillaritis**, but without granuloma formation, and does not involve the temporal arteries or lead to a decreased pulse in the manner described. *Takayasu arteritis* - Takayasu arteritis primarily affects the **aorta and its major branches**, leading to **claudication**, **pulse deficits** in the extremities, and often occurs in **younger women**. - While it can cause a decreased pulse, it is less likely to present with **temporal artery tenderness** and severe headache in a 65-year-old, as these symptoms are more characteristic of GCA.

Question 8: A 32-year-old woman presents to you for evaluation of headache. The headaches began at age 18, were initially unilateral and worse around the time of her menses. Initially the use of triptans two or three times a month would provide complete relief. Over the past several years, however, the headaches have become more frequent and severe. Triptans provide only partial relief; the patient requires a combination of acetaminophen, caffeine, and butalbital to achieve some improvement. Prophylactic medications including beta-blockers, tricyclics, and topiramate have been unsuccessful in preventing the headaches, and she has been to the emergency room three times over the past 2 weeks for a "pain shot." The general physical examination is unremarkable. Her funduscopic examination shows no evidence of papilledema, and a careful neurological examination is likewise normal. What is the most likely explanation for her headache syndrome?

A. CNS vasculitis
B. Status migrainosus
C. Medication overuse headache (Correct Answer)
D. Space-occupying intracerebral lesion

Explanation: The patient's history of increasing headache frequency and severity, decreased response to triptans, and frequent use of combination analgesics (acetaminophen, caffeine, butalbital) strongly suggests **medication overuse headache (MOH)**. This condition is characterized by daily or near-daily headaches in a patient with a primary headache disorder, caused or exacerbated by **chronic excessive use of acute headache medications** [1]. **CNS vasculitis** is less likely given the long history of headaches starting in menses (suggesting a primary headache disorder) [2]. While it can cause headaches, CNS vasculitis typically presents with acute or subacute onset of various neurological deficits. **Space-occupying intracerebral lesion** is unlikely given the normal neurological examination and absence of papilledema [2]. Headaches due to brain tumors often worsen over time, but are typically associated with other neurological signs or symptoms, such as focal deficits, which are not present here.

Question 9: Consider the following clinical features : 1. Raised ICP 2. Seizures 3. Focal deficit 4. Headache Which of the above clinical features are related to most brain tumours?

A. 2, 3 and 4 only
B. 1 and 2 only
C. 1, 2, 3 and 4 (Correct Answer)
D. 1, 2 and 3 only

Explanation: ***1, 2, 3 and 4*** - All four clinical features—**raised ICP**, **seizures**, **focal neurological deficits**, and **headache**—are commonly associated with brain tumors [1]. - Brain tumors can cause **increased intracranial pressure** through mass effect, edema, or CSF flow obstruction, leading to headaches and, less commonly, seizures [1]. **Focal deficits** result from direct tissue destruction or compression depending on the tumor's location [2]. *2, 3 and 4 only* - This option incorrectly omits **raised ICP**, which is a frequent and significant symptom of brain tumors, contributing to headaches, nausea, vomiting, and altered mental status [1]. - While seizures, focal deficits, and headaches are common, **raised ICP** often underlies many of these symptoms. *1 and 2 only* - This option excludes **focal deficits** and **headache**, both of which are very common presentations of brain tumors. - The specific location of a tumor often dictates **focal deficits** [2], and **headache** is one of the most prevalent symptoms. *1, 2 and 3 only* - This option incorrectly omits **headache**, which is a classic and highly prevalent symptom in patients with brain tumors, often severe and resistant to common analgesics. - Headaches can result from **mass effect**, **increased ICP** [1], or irritation of pain-sensitive structures within the brain.

Question 10: Which of the following is not used in the management of post-dural headache?

A. Hydration
B. Epidural blood patch
C. Propped up position (Correct Answer)
D. Sumatriptan

Explanation: ***Propped up position*** - Maintaining a **propped-up position** can worsen a post-dural puncture headache (PDPH) because it increases the hydrostatic pressure gradient on the brain, exacerbating the intracranial hypotension. - PDPH is typically relieved by lying **supine** and worsened by sitting or standing, indicating that an upright position is contraindicated for symptom relief. *Sumatriptan* - **Sumatriptan**, a selective serotonin receptor agonist, can be used to treat post-dural puncture headache (PDPH) in some patients, particularly if the headache has migrainous features. - It works by causing **vasoconstriction** of intracranial blood vessels, which may help reduce cerebral blood flow and alleviate headache pain. *Hydration* - **Hydration**, specifically increasing fluid intake, is a common and often effective conservative measure for managing post-dural puncture headache (PDPH). - Adequate hydration can help increase **cerebrospinal fluid (CSF) volume** and pressure, thereby reducing the severity of the headache caused by CSF leakage. *Epidural blood patch* - An **epidural blood patch (EBP)** is considered the definitive treatment for severe or persistent post-dural puncture headache (PDPH) that does not respond to conservative measures. - It involves injecting a small amount of the patient's own blood into the epidural space, forming a clot that seals the dural puncture site and **stops CSF leakage**.

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