Migraine and the Eye — MCQs
Migraine is due to
A patient presents with headache for one hour on awakening, associated with nasal stuffiness and reddening of eye. Suggestive of
A 64 year old lady Kamla complains of severe unilateral headache on the right side and blindness for 2 years. On examination there is a thick cord like structure on the lateral side of the head. The ESR is 80 mm/hr in the first hour. The most likely diagnosis is -
A 40-year-old male experiences flashes of light. Which of the following can likely be the reason?
A 20-year-old girl complains of headache while studying. Her vision is found to be normal. In the initial medical evaluation of her headache, which of the following would be the LEAST essential to assess?
A 35-year-old lady, Malti, has unilateral headache, nausea, vomiting, and visual blurring. The diagnosis is:
All of the following are seen in 3rd nerve palsy except
What is the yoke muscle of the right lateral rectus?
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:
Which of the following investigations is not necessary for evaluating optic neuritis?
Migraine and the Eye Indian Medical PG Practice Questions and MCQs
Question 1: Migraine is due to
- A. Constriction of cranial arteries
- B. Dilatation of cranial arteries
- C. Meningeal inflammation
- D. Cortical spreading depression (Correct Answer)
Explanation: ***Cortical spreading depression*** - **Cortical spreading depression (CSD)** is a wave of neuronal and glial depolarization that propagates across the cerebral cortex, which is now considered the most likely primary event triggering a migraine attack, particularly with aura [1]. - CSD leads to a complex cascade of events, including changes in cerebral blood flow, activation of the **trigeminal nervous system**, and the release of inflammatory mediators, all contributing to the headache and associated symptoms of migraine [1]. *Constriction of cranial arteries* - While **vasoconstriction** might occur in the **prodromal phase** or during the aura of migraine, it's not the primary cause of the headache itself. - The classic vascular theory of migraine, which posited vasoconstriction followed by vasodilation, has largely been refined by more comprehensive neurovascular models. *Dilatation of cranial arteries* - **Vasodilation** of meningeal and other cranial arteries is indeed a feature of the migraine headache phase, contributing to the painful throbbing sensation [1]. - However, this is largely considered a secondary event, a consequence of the activation of the **trigeminal-vascular system** triggered by upstream cortical events like CSD, rather than the initial cause of the migraine [1]. *Meningeal inflammation* - While activation of the **trigeminal nervous system** during a migraine attack does lead to the release of neuropeptides (e.g., **CGRP**, substance P) that can cause **neurogenic inflammation** in the meninges, this is a secondary phenomenon. - This **sterile inflammation** contributes to the pain but is not the initial trigger or *sine qua non* of a migraine attack.
Question 2: A patient presents with headache for one hour on awakening, associated with nasal stuffiness and reddening of eye. Suggestive of
- A. Cluster headache (Correct Answer)
- B. Migraine
- C. Tension headache
- D. All of the options
Explanation: ***Cluster headache*** - This presentation describes a **cluster headache**, which is characterized by **severe, unilateral pain** affecting the area around the eye, often accompanied by **autonomic symptoms** like nasal stuffiness and conjunctival injection (reddening of the eye). [1] [2] - Cluster headaches typically occur in **clusters**, with attacks lasting from 15 minutes to 3 hours, and frequently occur at the same time each day, often awakening the patient from sleep. [1] *Migraine* - **Migraines** usually involve **throbbing, pulsating pain** and are often accompanied by **photophobia, phonophobia**, and nausea/vomiting, which are not mentioned here. [3] - While migraines can cause eye symptoms, the combination with pronounced nasal stuffiness and the specific pattern of awakening and duration are more characteristic of cluster headaches. [1] *Tension headache* - **Tension headaches** are typically described as a **tight band or pressure** around the head, involving the entire head, and are generally **mild to moderate** in intensity. [2] - They lack the severe pain and distinct autonomic symptoms (nasal stuffiness, eye reddening) seen in this patient. *All of the options* - This option is incorrect because the specific combination of symptoms points clearly to a **cluster headache** and excludes migraines and tension headaches due to their distinct clinical features. - While all are types of headaches, their presentations vary significantly, making only one the most likely diagnosis in this scenario.
Question 3: A 64 year old lady Kamla complains of severe unilateral headache on the right side and blindness for 2 years. On examination there is a thick cord like structure on the lateral side of the head. The ESR is 80 mm/hr in the first hour. The most likely diagnosis is -
- A. Temporal arteritis (Correct Answer)
- B. Migraine
- C. Sinusitis
- D. Cluster headache
Explanation: ***Temporal arteritis*** - The combination of **unilateral headache**, **visual disturbances** (blindness), a **palpable temporal artery** (thick cord-like structure), and a **markedly elevated ESR** (80 mm/hr) in an elderly patient is highly suggestive of temporal arteritis (giant cell arteritis) [1]. - This condition is an **inflammatory vasculitis** that can lead to permanent vision loss if not promptly treated with corticosteroids [1]. *Migraine* - While migraines cause **unilateral headaches**, they typically present with **photophobia**, phonophobia, and aura, and are not associated with a palpable temporal artery or such a high ESR [1]. - Blindness is not a typical persistent symptom of migraine; visual disturbances are usually transient auras [3]. *Sinusitis* - Sinusitis causes **facial pain** and headache, often localized to the sinus regions, and may be accompanied by congestion and discharge. - It does not cause permanent blindness or present with a palpable temporal artery, nor does it typically result in an ESR of 80 mm/hr. *Cluster headache* - Cluster headaches are characterized by **severe unilateral pain**, retro-orbital location, and autonomic symptoms like **lacrimation** and **nasal congestion**, but they do not cause a palpable temporal artery, blindness, or an elevated ESR [2]. - The pain is usually episodic and short-lived, unlike the persistent symptoms described [2].
Question 4: A 40-year-old male experiences flashes of light. Which of the following can likely be the reason?
- A. Retinal detachment (Correct Answer)
- B. CRAO
- C. SAH
- D. Branch retinal artery occlusion
Explanation: ***Retinal detachment*** - Flashes of light, or **photopsia**, are a classic symptom of **retinal detachment**, often caused by the retina pulling away from the underlying choroid. - This sensation occurs as the detached retina is mechanically stimulated, sending abnormal signals to the brain that are interpreted as light flashes. *CRAO* - **Central Retinal Artery Occlusion (CRAO)** typically presents with **sudden, painless, severe vision loss** in one eye, not flashes of light. - The primary pathology is a blockage of blood flow to the retina, leading to **ischemia** and vision impairment. *SAH* - **Subarachnoid Hemorrhage (SAH)** is a neurological emergency characterized by **sudden, severe headache** (thunderclap headache), stiff neck, and altered mental status. - While it can cause visual disturbances, these are usually **diplopia** or **visual field defects** due to cranial nerve involvement, not flashes of light related to retinal pathology. *Branch retinal artery occlusion* - **Branch Retinal Artery Occlusion** causes **sudden, painless vision loss** in a specific part of the visual field corresponding to the occluded branch. - Like CRAO, it is an ischemic event and does not typically present with flashes of light; instead, it results in a **scotoma** or partial vision loss.
Question 5: A 20-year-old girl complains of headache while studying. Her vision is found to be normal. In the initial medical evaluation of her headache, which of the following would be the LEAST essential to assess?
- A. Family history of headache
- B. Menstrual history
- C. Fundoscopy examination
- D. Her interest in studies (Correct Answer)
Explanation: ***Her interest in studies*** - While **stress** and **academic pressure** can contribute to headaches, this represents a **psychosocial assessment** rather than a standard medical evaluation. - Among the listed options, this would be the **least essential** in the initial medical workup compared to the other clinical assessments. *Family history of headache* - Essential evaluation as many headache disorders, particularly **migraine** and **tension-type headache**, have strong **genetic predisposition**. - Family history helps establish diagnosis and guides appropriate management strategies for the patient's headaches. *Menstrual history* - Crucial in young women as **hormonal fluctuations** during the menstrual cycle are major triggers for headaches, especially **menstrual migraine**. - Understanding menstrual patterns can identify cyclical headache triggers and inform treatment approaches. *Fundoscopy examination* - Important to rule out **papilledema** (optic disc swelling) and signs of **increased intracranial pressure**, even with normal visual acuity. - Normal vision does not exclude underlying pathology that could be detected through **ophthalmoscopic examination** of the retina and optic nerve.
Question 6: A 35-year-old lady, Malti, has unilateral headache, nausea, vomiting, and visual blurring. The diagnosis is:
- A. Posterior fossa cyst
- B. Subarachnoid hemorrhage
- C. Glaucoma (Correct Answer)
- D. Cluster headache
Explanation: ***Glaucoma (Acute Angle-Closure)*** - The combination of **unilateral headache**, **nausea**, **vomiting**, and **visual blurring** is highly suggestive of **acute angle-closure glaucoma**. - This condition involves a sudden increase in **intraocular pressure**, which can cause a severe headache, often localized to the affected eye, and systemic symptoms due to vagal stimulation. *Posterior fossa cyst* - A posterior fossa cyst could cause headaches, nausea, and vomiting due to increased **intracranial pressure** or mass effect. - However, it typically presents with **bilateral** or generalized headache and specific neurological deficits related to cerebellar or brainstem compression, not typically unilateral visual blurring as the primary ocular symptom. *Subarachnoid hemorrhage* - A subarachnoid hemorrhage characteristically presents with a **sudden-onset**, severe "thunderclap" headache, often described as the "worst headache of my life." - While it can cause nausea and vomiting, visual blurring is not the primary or unilateral symptom, and the headache rarely gradually progresses as might be implied by "unilateral headache" without further qualification of its onset. *Cluster headache* - Cluster headaches are characterized by **severe unilateral pain**, typically around the eye or temple, accompanied by **autonomic symptoms** like tearing, nasal congestion, and ptosis on the affected side. - While visual blurring can occur, nausea and vomiting are less prominent than in acute glaucoma, and the pain is usually described as excruciating and stabbing, without the significant visual loss.
Question 7: All of the following are seen in 3rd nerve palsy except
- A. Ptosis
- B. Pupillary dilatation
- C. Loss of abduction (Correct Answer)
- D. Exotropia and hypotropia
Explanation: ***Correct Answer: Loss of abduction*** - **Abduction** (moving the eye laterally/outward) is controlled by the **lateral rectus muscle**, which is innervated by the **abducens nerve (CN VI)**, not the oculomotor nerve (CN III) - Therefore, **loss of abduction is NOT seen in 3rd nerve palsy** - it is characteristic of **6th nerve palsy** - This is the correct answer for this "EXCEPT" question *Incorrect: Ptosis* - **Ptosis** (drooping of the upper eyelid) is a **hallmark feature** of 3rd nerve palsy - Caused by paralysis of the **levator palpebrae superioris muscle** (innervated by CN III) - This IS seen in 3rd nerve palsy, so it's not the exception *Incorrect: Pupillary dilatation* - **Pupillary dilatation** (mydriasis) is a classic sign of **compressive 3rd nerve palsy** - The parasympathetic fibers running with CN III control pupillary constriction via the sphincter pupillae - When these fibers are damaged, unopposed sympathetic tone causes pupil dilation - This IS seen in 3rd nerve palsy (especially with compressive lesions), so it's not the exception *Incorrect: Exotropia and hypotropia* - **Exotropia** (eye deviated laterally) and **hypotropia** (eye deviated downward) occur in complete 3rd nerve palsy - Results from paralysis of muscles innervated by CN III: medial rectus, superior rectus, inferior rectus, and inferior oblique - With these muscles paralyzed, the **lateral rectus (CN VI)** and **superior oblique (CN IV)** act unopposed, causing the eye to be "down and out" - This IS seen in 3rd nerve palsy, so it's not the exception
Question 8: What is the yoke muscle of the right lateral rectus?
- A. Lt medial rectus (Correct Answer)
- B. Lt superior rectus
- C. Lt lateral rectus
- D. Lt inferior oblique
Explanation: ***Lt medial rectus*** - Yoke muscles are pairs of muscles in opposite eyes that produce **conjugate eye movements**, meaning they cause both eyes to move in the same direction. - When the **right lateral rectus** abducts (moves outward) the right eye, the **left medial rectus** adducts (moves inward) the left eye, both eyes gaze to the right. *Lt superior rectus* - The left superior rectus is primarily responsible for **elevation** and **intorsion** of the left eye. - It works synergistically with the right **inferior oblique** for upward gaze. *Lt lateral rectus* - The left lateral rectus is the primary muscle for **abduction** (moving outward) of the left eye. - It is not a yoke muscle for the right lateral rectus, as both perform similar actions in their respective eyes. *Lt inferior oblique* - The left inferior oblique primarily causes **extorsion**, **elevation**, and **abduction** of the left eye. - It works with the right superior rectus for upward gaze.
Question 9: 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 10: Which of the following investigations is not necessary for evaluating optic neuritis?
- A. MRI of the head and orbit
- B. Erythrocyte Sedimentation Rate (ESR)
- C. Ultrasonography B-scan (Correct Answer)
- D. Visual fields assessment
Explanation: **Explanation:** Optic neuritis is an inflammatory condition of the optic nerve, most commonly associated with Multiple Sclerosis (MS). The diagnosis is primarily clinical, but investigations are focused on confirming the diagnosis, assessing the extent of damage, and determining the risk of systemic demyelination. **Why B-scan is the correct answer:** **Ultrasonography B-scan** is used to visualize the posterior segment of the eye when the media (cornea, lens, or vitreous) is opaque. It is useful for detecting retinal detachment, vitreous hemorrhage, or intraocular tumors. It has no diagnostic value in optic neuritis because the pathology is retrobulbar or involves the nerve fibers, which are better visualized via neuroimaging. **Why the other options are necessary:** * **MRI of the head and orbit (with Gadolinium):** This is the most important investigation. It confirms optic nerve inflammation (showing enhancement) and identifies white matter plaques in the brain, which are crucial for predicting the risk of developing Multiple Sclerosis. * **Erythrocyte Sedimentation Rate (ESR):** While optic neuritis is usually idiopathic or demyelinating, ESR is checked to rule out inflammatory or systemic autoimmune mimics, such as Neuromyelitis Optica (NMO) or giant cell arteritis in older patients. * **Visual fields assessment:** Automated perimetry (e.g., Humphrey Visual Field) is essential to document the type of defect. The most common finding is a **central or centrocecal scotoma**. **Clinical Pearls for NEET-PG:** * **Classic Triad:** Sudden unilateral vision loss, periocular pain (worsened by eye movement), and dyschromatopsia (impaired red-green color vision). * **Marcus Gunn Pupil:** A Relative Afferent Pupillary Defect (RAPD) is a hallmark sign. * **Pulfrich Phenomenon:** Objects moving in a straight line appear to move in curved paths due to delayed conduction in the affected nerve. * **Uhthoff’s Phenomenon:** Temporary worsening of symptoms with increased body temperature (e.g., after a hot bath or exercise).
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