Headache Disorders — MCQs
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:
Prophylaxis for migraine -
Most common cause of cranial irradiation in children is
A 35-year-old with migraines needs prophylaxis. Which is suitable?
The following are recognized signs and symptoms of raised intracranial tension in a 9-month-old infant, except which of the following?
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 2-year-old boy has been doing well despite his diagnosis of tetralogy of Fallot. He presented to an outside ER a few days ago with a complaint of an acute febrile illness for which he was started on a "pink, bubble-gum tasting antibiotic." His mother reports that for the past 12 hours or so he has been holding his head saying it hurts and he is less active than normal. On your examination, he seems to have a severe headache, nystagmus, and ataxia. Which of the following would be the most appropriate first test to order?
An 8-year old child has difficulty walking and getting up from a squatting position. A muscle biopsy was done and is as shown in the image. Which of the following is true about this condition?
Headache Disorders 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: Prophylaxis for migraine -
- A. Amitriptyline (Correct Answer)
- B. Sumatriptan
- C. Diazepam
- D. Nifedipine
Explanation: ***Amitriptyline*** - **Amitriptyline**, a **tricyclic antidepressant**, is commonly used for migraine prophylaxis due to its neuromodulatory effects that can reduce headache frequency and severity. - It works by affecting neurotransmitters like **serotonin** and **norepinephrine**, which play a role in migraine pathophysiology. *Nifedipine* - **Nifedipine** is a **calcium channel blocker** primarily used for hypertension and angina, not typically for migraine prophylaxis. - While other calcium channel blockers like **verapamil** can be used for migraine, nifedipine is not a first-line or common choice. *Sumatriptan* - **Sumatriptan** is an **abortive medication** used to treat acute migraine attacks once they have started. - It works by constricting blood vessels and blocking pain pathways in the brain, but it is not used for chronic prevention. *Diazepam* - **Diazepam** is a **benzodiazepine** primarily used for anxiety, muscle spasms, and seizures due to its sedative and anxiolytic properties. - It is not indicated for migraine prophylaxis and can sometimes worsen headaches with chronic use or withdrawal.
Question 5: Most common cause of cranial irradiation in children is
- A. AML
- B. Small cell lung cancer
- C. Craniopharyngioma
- D. ALL (Acute Lymphoblastic Leukemia) (Correct Answer)
Explanation: **ALL (Acute Lymphoblastic Leukemia)** - **Acute Lymphoblastic Leukemia (ALL)** is the **most common childhood cancer**, and central nervous system (CNS) involvement is a significant concern, requiring prophylactic or therapeutic cranial irradiation. - Cranial irradiation is often used in the treatment of ALL to prevent or treat **CNS relapse**, which can occur due to the ability of leukemic cells to infiltrate the brain and spinal cord. *AML* - **Acute Myeloid Leukemia (AML)** can also involve the central nervous system, but it is less common than in ALL, and the primary treatment strategy may differ. - While cranial irradiation might be used in specific high-risk cases or for CNS relapse in AML, it is **not the most common cause** of cranial irradiation in children compared to ALL. *Small cell lung cancer (rare in children)* - **Small cell lung cancer** is exceedingly **rare in children**, making it an unlikely cause for cranial irradiation in this population. - Even in adults, while CNS metastasis is common, lung cancer itself is not a primary indication for routine *prophylactic* cranial irradiation in children. *Craniopharyngioma* - **Craniopharyngioma** is a type of brain tumor in children that may require surgery and sometimes **radiation therapy**, including focal cranial irradiation. - However, craniopharyngioma is **less common** than ALL, and thus, it does not represent the most frequent reason for cranial irradiation in children overall.
Question 6: A 35-year-old with migraines needs prophylaxis. Which is suitable?
- A. Acetaminophen
- B. Sumatriptan
- C. Verapamil (Correct Answer)
- D. Tramadol
Explanation: ***Verapamil*** - **Verapamil**, a calcium channel blocker, is often used off-label for **migraine prophylaxis**, particularly in cases where other first-line agents are contraindicated or ineffective. - While not a first-line treatment, it can reduce the frequency and severity of migraine attacks by modulating **vasoconstriction** and **vasodilation**. *Acetaminophen* - **Acetaminophen** is an analgesic used for **acute pain relief**, but it does not have properties that prevent migraine attacks from occurring. - It is unsuitable for long-term **prophylactic management** of migraines. *Sumatriptan* - **Sumatriptan** is a **triptan** medication used for **acute migraine treatment**, meaning it is taken to stop a migraine attack once it has started. - It is not indicated for **migraine prophylaxis** and should not be used regularly to prevent migraines. *Tramadol* - **Tramadol** is an **opioid analgesic** used for moderate to severe pain, and it carries risks of dependence and side effects. - It is not recommended for **migraine prophylaxis** due to its addictive potential and lack of evidence for preventing migraine attacks.
Question 7: The following are recognized signs and symptoms of raised intracranial tension in a 9-month-old infant, except which of the following?
- A. Vomiting
- B. Papilledema
- C. Normal head circumference (Correct Answer)
- D. Bulging fontanel
Explanation: ***Normal head circumference*** - **Raised intracranial tension (RIC)** in infants often leads to an **increased head circumference** if the sutures have not yet fused, making a normal circumference *less likely* for RIC. - A persistent increase in head circumference is a key indicator of **hydrocephalus** or other conditions causing RIC in infants. *Bulging fontanel* - A **full or bulging fontanel** is a classic sign of RIC in infants because the open fontanelle provides a direct route for pressure to manifest. - This occurs due to increased pressure within the skull pushing the brain and cerebrospinal fluid outwards. *Papilledema* - **Papilledema**, or swelling of the optic disc, indicates increased pressure transmitted to the optic nerve. - While it can be harder to detect in infants than in older children, it is a significant sign of RIC when present. *Vomiting* - **Vomiting**, especially projectile vomiting without associated nausea, is a common non-specific symptom of RIC in infants and children. - This is thought to be due to pressure on the **brainstem's emetic center**.
Question 8: 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 9: A 2-year-old boy has been doing well despite his diagnosis of tetralogy of Fallot. He presented to an outside ER a few days ago with a complaint of an acute febrile illness for which he was started on a "pink, bubble-gum tasting antibiotic." His mother reports that for the past 12 hours or so he has been holding his head saying it hurts and he is less active than normal. On your examination, he seems to have a severe headache, nystagmus, and ataxia. Which of the following would be the most appropriate first test to order?
- A. CT or MRI of the brain (Correct Answer)
- B. Lumbar puncture
- C. Urine drug screen
- D. Blood culture
Explanation: ***CT or MRI of the brain*** - The patient's history of **tetralogy of Fallot** puts him at increased risk for a **brain abscess** due to right-to-left shunting, bypassing pulmonary filtration of bacteria. - New onset of severe headache, nystagmus, and ataxia in this context strongly suggests an **intracranial mass lesion**, making immediate imaging crucial. *Lumbar puncture* - Performing a **lumbar puncture** in the presence of signs of elevated intracranial pressure (severe headache, nystagmus, ataxia) or suspicion of a mass lesion (brain abscess) is **contraindicated** due to the risk of herniation. - While it can diagnose meningitis, the clinical picture with focal neurological signs makes a mass lesion a higher concern that needs to be ruled out first. *Urine drug screen* - The patient's symptoms (severe headache, nystagmus, ataxia) are not typical for drug intoxication in a 2-year-old, especially given the history of a recent febrile illness and a congenital heart defect. - There is no clinical indication for drug use in this young child, and this test would not address the serious neurological symptoms. *Blood culture* - While a blood culture might be useful to identify a systemic infection, it will not directly explain or diagnose the acute focal neurological deficits such as nystagmus and ataxia, and the severe headache. - Given the high suspicion of an intracranial lesion with risk of herniation, obtaining imaging is a higher priority than waiting for blood culture results, which would take time.
Question 10: An 8-year old child has difficulty walking and getting up from a squatting position. A muscle biopsy was done and is as shown in the image. Which of the following is true about this condition?
- A. Previous history of viral prodrome
- B. It is a mitochondrial storage disorder
- C. Early treatment has excellent prognosis
- D. Death occurs in the 3rd decade for certain types of muscular dystrophy. (Correct Answer)
Explanation: ***Death occurs in the 3rd decade for certain types of muscular dystrophy.*** - The image shows muscle fibers with varying sizes and **necrosis**, along with areas of **regeneration** and **fibrosis**, which are characteristic findings in **muscular dystrophies**, particularly Duchenne muscular dystrophy. - In **Duchenne muscular dystrophy**, patients often succumb to **respiratory or cardiac complications** by their **late teens or early twenties (3rd decade)**, making this statement true for this condition. *Previous history of viral prodrome* - A **viral prodrome** is typically associated with **acute viral myositis** or **polymyositis**, which are inflammatory conditions, not primarily genetic muscular dystrophies. - While viral infections can sometimes trigger symptoms or exacerbate underlying conditions, a direct causal link as a defining feature of muscular dystrophy is incorrect. *It is a mitochondrial storage disorder* - **Mitochondrial storage disorders** involve dysfunction of the mitochondria and can manifest as myopathies, but the histological features (ragged red fibers) and clinical presentation often differ from the classic presentation of muscular dystrophy. - The image and clinical context point towards a **dystrophinopathy**, not a primary mitochondrial disorder. *Early treatment has excellent prognosis* - Despite advances in care, **muscular dystrophies**, especially Duchenne, remain **progressive and incurable**, with treatments aimed at slowing progression and managing symptoms rather than achieving a cure or excellent prognosis. - **Early diagnosis and intervention** can improve quality of life and prolong survival but do not lead to an "excellent prognosis" in terms of disease reversal or complete functional recovery.
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