Headache Disorders — MCQs
Post dural puncture headache usually presents within ?
All of the following are trigeminal autonomic cephalgias except
A female patient presents to you with a unilateral headache. It is associated with nausea, photophobia, and phonophobia. What is the drug of choice for acute management?
A patient presented with sudden onset of thunderclap headache & dilated pupils. Findings are consistent with:
A 65-year-old patient presents with severe headache, temporal artery tenderness, and decreased pulse. What is the most likely diagnosis?
What is not a feature of raised ICP
A 10 year old child presented with headache, vomiting, gait instability and diplopia. On examination he had papilledema and gait ataxia. The most probable diagnosis is –
A 68-year-old patient presents with sudden onset of right-sided weakness and slurred speech. The symptoms completely resolve within 30 minutes with no residual neurological deficits. This clinical presentation is most consistent with:
Which of the following is commonly seen in Pituitary apoplexy?
A 50 year old man presents with brief episodes of lancinating unilateral facial pain, involving the buccal distribution. Pain is triggered by washing face with cold water. What is the most likely diagnosis?
Headache Disorders Indian Medical PG Practice Questions and MCQs
Question 1: Post dural puncture headache usually presents within ?
- A. 0-6 Hrs
- B. 6-12 Hrs
- C. 12-72 Hrs (Correct Answer)
- D. 72-96 Hrs
Explanation: ***12-72 Hrs*** - The onset of a **post-dural puncture headache (PDPH)** typically occurs within **12 to 72 hours** after the dural puncture. - This delay is thought to be related to the time it takes for significant **cerebrospinal fluid (CSF) leakage** and corresponding intracranial hypotension to develop. *0-6 Hrs* - Headaches presenting within this timeframe are less likely to be true **PDPH** as the typical latency period for significant CSF leakage and its symptomatic effects hasn't usually manifested. - Such early headaches might be due to other causes like **anxiety**, **dehydration**, or mild irritation from the procedure. *6-12 Hrs* - While possible, onset within this timeframe is less common than the 12-72 hour window for **classic PDPH**. - Moderate **CSF leakage** might lead to symptoms in some individuals, but the vast majority present later. *72-96 Hrs* - Although PDPH can persist for days or even weeks, its **onset** is significantly less common in this range. - A headache beginning this late may prompt consideration of other differential diagnoses, though late-onset PDPH is not unheard of.
Question 2: All of the following are trigeminal autonomic cephalgias except
- A. Short lasting unilateral neuralgiform headache attacks
- B. Tension type headache (Correct Answer)
- C. Episodic cluster headache
- D. Paroxysmal hemicranias
Explanation: ***Tension type headache*** - **Tension-type headaches** are characterized by a bilateral, pressing, or tightening quality, *without* the prominent autonomic symptoms seen in trigeminal autonomic cephalgias [1]. - They are generally not associated with activation of the **trigeminal autonomic reflex**, which is central to TACs. *Short lasting unilateral neuralgiform headache attacks* - These are characterized by **short-lasting** attacks of severe, unilateral head pain accompanied by **prominent trigeminal autonomic features**. - This category includes SUNCT (Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing) and SUNA (Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms) and are indeed trigeminal autonomic cephalgias. *Episodic cluster headache* - **Cluster headaches** are the most well-known of the trigeminal autonomic cephalgias, characterized by severe, unilateral pain in the orbital, supraorbital, or temporal regions [1]. - They are invariably accompanied by **ipsilateral autonomic symptoms** like lacrimation, conjunctival injection, nasal congestion, and ptosis [2]. *Paroxysmal hemicranias* - This condition involves frequent, short-lasting attacks of **severe, unilateral pain** typically in the orbital, supraorbital, or temporal regions. - It is consistently associated with prominent **ipsilateral autonomic features** and shows an absolute response to **indomethacin**, distinguishing it from other TACs.
Question 3: A female patient presents to you with a unilateral headache. It is associated with nausea, photophobia, and phonophobia. What is the drug of choice for acute management?
- A. Flunarizine
- B. Sumatriptan (Correct Answer)
- C. Propranolol
- D. Topiramate
Explanation: ***Sumatriptan*** - **Sumatriptan**, a **triptan**, is an effective abortive therapy for **acute migraine attacks** due to its selective serotonin 5-HT1B/1D receptor agonist action, leading to vasoconstriction and inhibition of neurogenic inflammation. - The symptoms described—**unilateral headache**, nausea, **photophobia**, and **phonophobia**—are classic features of migraine. *Flunarizine* - **Flunarizine** is a **calcium channel blocker** used for migraine **prophylaxis**, not for acute treatment. - It is typically prescribed for patients experiencing frequent or severe migraine attacks to reduce their incidence. *Propranolol* - **Propranolol** is a **beta-blocker** primarily used for migraine **prophylaxis**. - It helps prevent migraine attacks by modulating cerebral blood flow and neuronal excitability, but it is not effective for acute pain relief during an attack. *Topiramate* - **Topiramate** is an **antiepileptic drug** often used for migraine **prophylaxis**. - It works by various mechanisms, including altering neurotransmitter activity, but it does not provide acute symptomatic relief for an ongoing migraine attack.
Question 4: A patient presented with sudden onset of thunderclap headache & dilated pupils. Findings are consistent with:
- A. Brain stem encephalitis
- B. Acute aneurismal hemorrhage (Correct Answer)
- C. Acute ischemia of midbrain
- D. Meningitis
Explanation: ***Acute aneurismal hemorrhage*** - **Thunderclap headache** is the hallmark symptom, often described as the "worst headache of life," due to sudden elevation of intracranial pressure [2]. - **Dilated pupils**, especially unilateral, can indicate compression of the **oculomotor nerve (CN III)** by an expanding aneurysm in the posterior communicating artery region, a direct effect of subarachnoid hemorrhage [1]. *Brain stem encephalitis* - This condition involves inflammation of the brainstem, which typically presents with a range of neurological deficits such as **ataxia**, **cranial nerve palsies**, and **altered consciousness**. - While headaches can occur, a characteristic **thunderclap headache** is not a typical feature, and pupillary abnormalities would be more varied depending on the extent of brainstem involvement. *Acute ischemia of midbrain* - **Midbrain ischemia** would present with brainstem symptoms like **vertigo**, **diplopia**, **hemiparesis**, or **oculomotor nerve palsy** [3]. - Although it could lead to pupillary changes if the oculomotor nucleus is affected, it typically does not cause a sudden, severe **thunderclap headache**. *Meningitis* - **Meningitis** presents with headache, fever, **neck stiffness**, and altered mental status [2]. - While headache is common, a sudden **thunderclap headache** is less typical, and **dilated pupils** are not a primary diagnostic feature unless there is severe herniation or other complications.
Question 5: 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 6: What is not a feature of raised ICP
- A. Vomiting
- B. Tachycardia (Correct Answer)
- C. Blurring of vision
- D. Hypertension
Explanation: ***Tachycardia*** - **Bradycardia**, not tachycardia, is a classic component of the **Cushing's triad**, which is a physiological response to increased ICP. - The elevated ICP triggers a reflex arc that causes a decrease in heart rate as the body attempts to maintain cerebral perfusion. *Vomiting* - **Vomiting**, especially projectile and without nausea, is a common symptom of increased ICP due to activation of the **chemoreceptor trigger zone** in the medulla. - The pressure directly stimulates this area, leading to emesis. *Blurring of vision* - **Blurring of vision** is a frequent symptom of raised ICP, often associated with **papilledema** (swelling of the optic disc). - The elevated pressure is transmitted to the optic nerve sheath, impeding venous return and causing nerve swelling. *Hypertension* - **Hypertension** is part of the **Cushing's triad** in response to increased ICP, where the body raises systemic blood pressure to overcome resistance and maintain cerebral blood flow [2]. - This is a compensatory mechanism to ensure adequate perfusion to the brain [1].
Question 7: A 10 year old child presented with headache, vomiting, gait instability and diplopia. On examination he had papilledema and gait ataxia. The most probable diagnosis is –
- A. Suprasellar tumour
- B. Hydrocephalus
- C. Brain stem tumour
- D. Midline posterior fossa tumour (Correct Answer)
Explanation: ***Midline posterior fossa tumour*** - The combination of **headache, vomiting, papilledema (signs of increased intracranial pressure)**, **gait instability, and ataxia** strongly suggests a **midline posterior fossa tumor** in a child. These tumors often obstruct CSF flow, leading to hydrocephalus and cerebellar symptoms. - Common tumors in this location in children include **medulloblastoma** and **pilocytic astrocytoma**, which frequently present with these symptoms due to their proximity to the **fourth ventricle** and **cerebellum**. *Suprasellar tumour* - **Suprasellar tumors** typically present with **visual field deficits** (e.g., bitemporal hemianopia) due to compression of the optic chiasm, and/or **endocrine dysfunction** (e.g., growth delay, diabetes insipidus). - While they can cause hydrocephalus and increased intracranial pressure if large, the prominent **gait instability and ataxia** point away from a primary suprasellar lesion as the most likely cause. *Hydrocephalus* - **Hydrocephalus** itself explains the **increased intracranial pressure (headache, vomiting, papilledema)** and sometimes **gait instability (ataxia)**. - However, hydrocephalus is usually a *consequence* of an underlying obstruction, and in a child presenting acutely with cerebellar dysfunction, a **tumor blocking CSF flow in the posterior fossa** is the most probable underlying cause, not hydrocephalus as the primary diagnosis. *Brain stem tumour* - **Brain stem tumors** typically cause **cranial nerve deficits** (e.g., facial weakness, dysphagia), **long tract signs (hemiparesis)**, and often **multiple types of ataxia**, alongside signs of increased intracranial pressure if they obstruct CSF flow. - While gait instability and diplopia can occur, the overall picture of prominent **gait ataxia** and papilledema without other focal cranial nerve signs makes a primary midline posterior fossa tumor compressing the cerebellum and fourth ventricle more likely.
Question 8: A 68-year-old patient presents with sudden onset of right-sided weakness and slurred speech. The symptoms completely resolve within 30 minutes with no residual neurological deficits. This clinical presentation is most consistent with:
- A. Transient Ischemic Attack (TIA) (Correct Answer)
- B. Subarachnoid hemorrhage
- C. Intracerebral hemorrhage
- D. Ischemic stroke
Explanation: ***Transient Ischemic Attack (TIA)*** - A TIA is characterized by **transient neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia**, without acute infarction [1]. - The key diagnostic feature here is the **complete resolution of symptoms within a short period** (30 minutes) with no residual deficits, fitting the definition of TIA [1]. *Subarachnoid hemorrhage* - This typically presents with a **sudden, severe headache** (often described as "thunderclap"), stiff neck, and altered mental status. - While it can cause sudden neurological deficits, these symptoms usually **do not resolve completely within minutes**, and often lead to persistent deficits or life-threatening complications. *Intracerebral hemorrhage* - An intracerebral hemorrhage involves **bleeding directly into the brain tissue**, leading to sudden onset of neurological deficits that **progress over time** [2]. - The symptoms are generally **severe and persistent**, and would not resolve completely within 30 minutes. *Ischemic stroke* - An ischemic stroke is caused by a **blockage of blood flow to the brain**, resulting in brain tissue damage (infarction) and persistent neurological deficits [2]. - While initial symptoms can be similar to a TIA [3], an ischemic stroke by definition involves **permanent damage and lasting deficits**, unlike what is described in the patient's presentation.
Question 9: Which of the following is commonly seen in Pituitary apoplexy?
- A. Headache (Correct Answer)
- B. Hypertension
- C. Hypotension
- D. Vomiting
Explanation: ***Headache*** - **Severe headache** is the most common symptom of pituitary apoplexy, resulting from the sudden expansion of a pituitary mass due to hemorrhage or infarction [1]. - The rapid increase in pressure within the sella turcica, especially on the **dura mater**, causes intense pain. *Hypertension* - While stress can elevate blood pressure, **hypertension** is not a characteristic or direct symptom of acute pituitary apoplexy itself. - Instead, the condition often leads to **adrenal insufficiency**, which is associated with hypotension [1]. *Hypotension* - **Hypotension** is a common and serious manifestation of pituitary apoplexy, often due to acute **adrenal insufficiency** caused by the destruction of ACTH-producing cells [1]. - Reduced ACTH leads to decreased cortisol production, impairing vascular tone and fluid balance. *Vomiting* - **Vomiting** is a common symptom in pituitary apoplexy, often accompanying the severe headache. - It results from the increased **intracranial pressure** and irritation of pathways in the brainstem.
Question 10: A 50 year old man presents with brief episodes of lancinating unilateral facial pain, involving the buccal distribution. Pain is triggered by washing face with cold water. What is the most likely diagnosis?
- A. Chronic paroxysmal hemicrania
- B. Migraine
- C. Medication overuse headache
- D. Trigeminal neuralgia (Correct Answer)
Explanation: ***Trigeminal neuralgia*** - This condition presents with **brief, lancinating, unilateral facial pain** affecting one or more branches of the trigeminal nerve. - Pain is often **triggered by tactile stimuli** like washing the face, touching the face, or cold water, consistent with the patient's presentation. *Chronic paroxysmal hemicrania* - This type of headache is characterized by **frequent, short-lived attacks of severe, unilateral head pain**, often accompanied by autonomic symptoms (e.g., lacrimation, rhinorrhea). - It is crucial to note that these headaches are **responsive to indomethacin**, and while unilateral, they typically involve periorbital or temporal regions and not specifically the trigeminal distribution or tactile triggers in the same way. *Migraine* - Migraines are typically characterized by **pulsating, moderate to severe head pain**, often unilateral, lasting from hours to days [1]. - They are usually associated with **nausea, vomiting**, and sensitivity to light (photophobia) and sound (phonophobia), which are absent in this patient's presentation [2]. *Medication overuse headache* - This headache is a **chronic daily or near-daily headache** that develops or worsens due to the overuse of acute headache medications [2]. - It does not present with **brief, lancinating pains** or specific triggers like washing the face with cold water.
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