All questions
Question 1
A 42-year-old woman with a history of migraines reports that her headaches have been increasing in frequency over the past year. She now experiences debilitating, unilateral, throbbing headaches 5-7 times per month, causing her to miss work on at least two of those days. She uses over-the-counter naproxen and prescription rizatriptan for acute attacks, which helps shorten the duration but does not prevent their occurrence. She is frustrated with the impact on her quality of life.
Which of the following is the most appropriate management strategy to offer this patient?
- Increase the frequency of rizatriptan use
- Initiate prophylactic therapy with topiramate (correct answer)
- Recommend a trial of butalbital-containing analgesics
- Obtain an electroencephalogram (EEG)
Explanation: Prophylactic therapy is indicated for patients with frequent (≥4 per month) or debilitating migraines, or for those whose acute treatments are ineffective or contraindicated. This patient's headache frequency and impact on her life meet the criteria for initiating prophylaxis. Topiramate is a first-line, FDA-approved medication for migraine prevention. Increasing the use of abortive medications like triptans can lead to medication overuse headache. Butalbital-containing compounds have a high risk of dependence and medication overuse headache and are generally avoided. An EEG is not indicated in the evaluation of typical migraines.
Question 2
A 45-year-old man presents with a 2-week history of recurrent, debilitating headaches. He reports that the headaches occur once or twice daily, often waking him from sleep. The pain is extremely severe, sharp, and centered behind his right eye. Each episode lasts for about 60 minutes and is accompanied by right-sided tearing, eye redness, and nasal stuffiness. During the attacks, he feels restless and paces the room.
What is the most likely diagnosis?
- Migraine without aura
- Tension-type headache
- Acute angle-closure glaucoma
- Cluster headache (correct answer)
Explanation: This presentation is pathognomonic for cluster headache. Key features include the male predominance, circadian rhythmicity (waking from sleep), short duration of attacks (15-180 minutes), severe unilateral periorbital pain, and associated ipsilateral cranial autonomic symptoms (lacrimation, conjunctival injection, nasal congestion). The associated restlessness or agitation is also characteristic. Migraine is typically throbbing and associated with photophobia/phonophobia. Tension headache is a dull, bilateral pressure. Acute glaucoma presents with a painful red eye and blurry vision/halos, but not typically in this recurrent, short-lived pattern.
Question 3
A 52-year-old woman with a history of hypertension is brought to the emergency department after a sudden, severe headache that she describes as a "thunderclap" and "the worst headache of my life." The onset was instantaneous while she was lifting a heavy box. She appears distressed and is holding her head. Her blood pressure is 190/105 mmHg, and she has mild neck stiffness on examination. Her neurologic exam is otherwise nonfocal.
Which of the following is the most appropriate initial diagnostic step?
- Administer intravenous labetalol
- Perform a lumbar puncture
- Obtain a non-contrast CT scan of the head (correct answer)
- Order an MRI of the brain with contrast
Explanation: A sudden-onset, "thunderclap" headache is a neurologic emergency highly concerning for subarachnoid hemorrhage (SAH). The first-line diagnostic test is a non-contrast head CT, which is highly sensitive for detecting acute blood in the subarachnoid space. While controlling her blood pressure is important, diagnosis must be established first. A lumbar puncture is the next step if the CT is negative but clinical suspicion for SAH remains high. MRI is less sensitive for acute hemorrhage than CT.
Question 4
A 35-year-old accountant presents with a 4-month history of headaches. He describes the pain as a bilateral, tight, "band-like" pressure around his head that is mild to moderate in intensity. The headaches typically start in the afternoon on workdays and are not associated with nausea, vomiting, or sensitivity to light or sound. He is able to continue working through the headaches. His neurologic examination is normal.
What is the most likely diagnosis?
- Migraine without aura
- Medication overuse headache
- Tension-type headache (correct answer)
- Idiopathic intracranial hypertension
Explanation: This patient's symptoms are characteristic of tension-type headache, the most common type of primary headache. Key features include the bilateral location, non-pulsating or 'band-like' quality, mild-to-moderate intensity, and lack of associated features like nausea, photophobia, or phonophobia. The headache does not worsen with routine activity. Migraines are typically unilateral, pulsating, and have associated symptoms. Medication overuse headache requires a history of frequent analgesic use. Idiopathic intracranial hypertension typically presents with features of increased intracranial pressure like papilledema and visual changes.
Question 5
A 21-year-old college student is brought to the clinic by her roommate after she fainted during a heated argument. The roommate reports that just before losing consciousness, the patient complained of feeling lightheaded, nauseous, and sweaty. She was unresponsive for less than a minute and then awoke, feeling tired but otherwise back to her baseline without any confusion. Her past medical history is unremarkable. Her physical examination, including orthostatic vital signs and cardiac exam, is normal.
What is the most likely cause of this patient's loss of consciousness?
- Cardiogenic syncope
- Generalized seizure
- Orthostatic hypotension
- Vasovagal syncope (correct answer)
Explanation: This is a classic presentation of vasovagal (neurally mediated) syncope. The key features are a clear precipitating event (emotional stress), a characteristic prodrome of autonomic activation (lightheadedness, nausea, diaphoresis), a brief period of unconsciousness, and a rapid return to baseline without a significant postictal period. Cardiogenic syncope is less likely in a young, healthy individual and often occurs with exertion or without warning. A seizure would typically be associated with a postictal state of confusion. Orthostatic hypotension is related to postural changes, which was not the trigger here.
Question 6
A 45-year-old obese woman presents with a 3-month history of a daily, generalized headache. The headache is worse in the morning and is exacerbated by coughing or bending forward. She also reports transient episodes of vision loss that last a few seconds, particularly when she stands up, and a 'whooshing' sound in her ears that is synchronous with her pulse. Funduscopic examination reveals bilateral optic disc swelling.
Which of the following is the most likely diagnosis?
- Migraine
- Brain tumor
- Idiopathic intracranial hypertension (correct answer)
- Tension-type headache
Explanation: This patient's constellation of symptoms is highly suggestive of idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri. This condition is most common in obese women of childbearing age. Key features include headache with signs of increased intracranial pressure (worse with Valsalva, morning predominance), papilledema (optic disc swelling), transient visual obscurations, and pulsatile tinnitus. While a brain tumor can cause similar symptoms of increased ICP, IIH is more likely given the patient's demographic profile and the classic symptom cluster. A brain imaging (MRI) would be needed to rule out a structural lesion.
Question 7
A 78-year-old man with a history of hypertension and benign prostatic hyperplasia reports several episodes of dizziness and one episode of falling upon standing up from a seated position. He denies chest pain, palpitations, or focal neurologic symptoms. His medications include hydrochlorothiazide, amlodipine, and tamsulosin. On examination, his supine blood pressure is 145/85 mmHg with a heart rate of 72/min. After standing for 3 minutes, his blood pressure is 120/75 mmHg with a heart rate of 85/min.
The patient's symptoms are most likely due to which of the following?
- Benign paroxysmal positional vertigo
- Carotid artery stenosis
- Orthostatic hypotension (correct answer)
- Cardiac arrhythmia
Explanation: This patient has orthostatic hypotension, defined as a drop in systolic blood pressure of ≥20 mmHg or diastolic blood pressure of ≥10 mmHg within 3 minutes of standing. His blood pressure dropped by 25 mmHg systolic. This is a common cause of syncope and presyncope in the elderly, often exacerbated by medications such as diuretics (hydrochlorothiazide), calcium channel blockers (amlodipine), and alpha-blockers (tamsulosin). BPPV causes vertigo, not syncope. Carotid stenosis and arrhythmias are less likely given the clear postural trigger.
Question 8
A 24-year-old man is brought to the emergency department after a witnessed loss of consciousness at a party. A friend reports that the patient suddenly stared blankly, then his body became rigid, and he fell to the ground. This was followed by rhythmic jerking of his arms and legs for about one minute. After the event, he was confused and disoriented for 15-20 minutes. The patient has no memory of the event but reports biting the side of his tongue.
These clinical features are most characteristic of which of the following?
- Vasovagal syncope
- Cardiogenic syncope with myoclonic jerks
- Generalized tonic-clonic seizure (correct answer)
- Psychogenic nonepileptic seizure
Explanation: The constellation of features—a tonic phase (rigidity) followed by a clonic phase (rhythmic jerking), tongue biting (especially lateral), and a prolonged postictal state of confusion—is highly characteristic of a generalized tonic-clonic seizure. While syncope can sometimes be associated with brief myoclonic jerks due to cerebral hypoxia, the prolonged and organized tonic-clonic activity and the significant postictal phase strongly point towards a seizure. Psychogenic nonepileptic seizures often have asynchronous movements, pelvic thrusting, and are not typically associated with a postictal state or significant injury like tongue biting.
Question 9
A 68-year-old man presents with a TIA characterized by transient right arm weakness and aphasia. His medical history includes hypertension. An urgent carotid ultrasound reveals a 90% stenosis of the left internal carotid artery. He has been started on high-intensity statin therapy and aspirin.
Which of the following interventions is most likely to reduce his risk of a future stroke?
- Adding clopidogrel for long-term dual antiplatelet therapy
- Initiating anticoagulation with warfarin
- Performing carotid endarterectomy (correct answer)
- Repeating carotid ultrasound in 6 months
Explanation: For patients with a recent TIA or minor ischemic stroke who have symptomatic, high-grade (70-99%) stenosis of the internal carotid artery, carotid endarterectomy (CEA) has been shown to provide a significant reduction in the risk of subsequent stroke when added to best medical therapy. The benefit is greatest when the procedure is performed within two weeks of the event. Long-term dual antiplatelet therapy is not generally recommended over monotherapy outside of specific situations. Warfarin is for cardioembolic sources (e.g., atrial fibrillation). Surveillance alone is insufficient for this degree of symptomatic stenosis.
Question 10
A 29-year-old woman presents with frequent headaches that are mild, bilateral, and described as a "dull ache" or pressure. They occur 3-4 times a week, especially after long days at work, and are relieved by over-the-counter analgesics. She denies nausea, photophobia, or aura. She is concerned about the frequency of the headaches and asks for a preventive medication. She has no significant medical history.
Which of the following is the most appropriate prophylactic treatment for this patient's condition?
- Sumatriptan
- Verapamil
- Oxycodone
- Amitriptyline (correct answer)
Explanation: The patient's symptoms are consistent with frequent episodic tension-type headache. When these headaches are frequent and bothersome enough to warrant prophylaxis, amitriptyline is a first-line pharmacologic option. Behavioral therapies and stress management are also important. Sumatriptan is an abortive therapy for migraine. Verapamil is used for cluster headache prophylaxis. Oxycodone is an opioid and is not appropriate for headache management.
Question 11
A 28-year-old woman presents to her primary care physician with a 6-month history of recurrent, severe headaches. She reports that before the headache begins, she sees flashing, zigzag lines in her right visual field that last for about 20 minutes. This is followed by a severe, throbbing, left-sided headache associated with nausea and extreme sensitivity to light and sound. The headache phase typically lasts for 8 to 12 hours. Her neurologic examination is normal.
What is the most likely diagnosis?
- Migraine with aura (correct answer)
- Transient ischemic attack
- Cluster headache
- Tension-type headache
Explanation: This patient's presentation is classic for migraine with aura. The key features include a visual aura (scintillating scotoma) followed by a unilateral, throbbing headache associated with photophobia and phonophobia. A transient ischemic attack typically presents with negative neurologic phenomena (e.g., vision loss, weakness) rather than the positive phenomena (flashing lights) seen here, and is not typically followed by a severe headache. Cluster headaches are characterized by excruciating, unilateral periorbital pain with autonomic symptoms and are more common in men. Tension-type headaches are typically bilateral, non-throbbing, and lack associated features like aura or severe nausea.
Question 12
A 50-year-old woman with a 20-year history of migraines presents for evaluation. She states that for the past year, her headaches have changed. She now has a headache nearly every day, which she describes as a constant, dull, bilateral ache. She takes an over-the-counter analgesic containing acetaminophen, aspirin, and caffeine almost daily, often taking 4-6 tablets per day to 'keep the headache away'.
What is the most appropriate initial step in her management?
- Initiate prophylactic therapy with propranolol
- Refer for acupuncture and physical therapy
- Advise discontinuation of the over-the-counter analgesic (correct answer)
- Increase the dose of her analgesic for better control
Explanation: This patient's presentation is classic for medication overuse headache (MOH). This occurs when a patient with a pre-existing primary headache disorder develops a new type of headache or a marked worsening of their existing one due to the frequent use of acute headache medications. The first and most critical step in management is to discontinue the offending medication. Prophylactic therapies are unlikely to be effective until the overused medication is stopped. Increasing the dose would worsen the problem.
Question 13
A 38-year-old man is diagnosed with episodic cluster headache. He is currently in a 4-week cluster period, experiencing one to three severe attacks daily. He uses subcutaneous sumatriptan, which is effective for aborting the attacks. He wishes to start a medication to prevent the headaches from occurring during this period.
Which of the following is the most appropriate first-line medication for prophylaxis of cluster headache?
- Propranolol
- Verapamil (correct answer)
- Amitriptyline
- Ibuprofen
Explanation: Verapamil, a calcium channel blocker, is the first-line prophylactic agent for preventing cluster headaches. It is typically started at the beginning of a cluster period and tapered off after the period is over. Propranolol and amitriptyline are first-line prophylactic agents for migraine, not cluster headache. Ibuprofen is an analgesic used for acute pain and is not effective as prophylaxis for cluster headaches.
Question 14
A 74-year-old woman presents with a 2-week history of a new-onset headache, primarily over her right temple. She also complains of pain in her jaw when she chews and some transient episodes of blurred vision in her right eye. On examination, there is tenderness to palpation over the right temporal artery. Her erythrocyte sedimentation rate is 105 mm/hr.
Which of the following is the most appropriate immediate step in management?
- Schedule a temporal artery biopsy
- Initiate high-dose oral prednisone (correct answer)
- Order a CT angiogram of the head and neck
- Prescribe a short course of NSAIDs
Explanation: This patient's presentation of new-onset headache in an elderly individual, jaw claudication, visual symptoms, and a markedly elevated ESR is highly suspicious for giant cell arteritis (GCA). GCA is a medical emergency because it can lead to irreversible blindness from anterior ischemic optic neuropathy. Therefore, treatment with high-dose systemic corticosteroids (e.g., prednisone) should be initiated immediately to prevent vision loss. A temporal artery biopsy should be arranged to confirm the diagnosis, but treatment should not be delayed while awaiting the procedure or its results.
Question 15
A 48-year-old man with a known diagnosis of cluster headaches presents to the emergency department 15 minutes after the onset of a severe, right-sided periorbital headache. He is agitated, pacing, and has ipsilateral lacrimation and nasal congestion. He rates his pain as 10/10.
Which of the following is the most appropriate initial therapy?
- Oral ibuprofen
- High-flow oxygen administration (correct answer)
- Intravenous ketorolac
- Oral propranolol
Explanation: The first-line abortive treatments for an acute cluster headache attack are 100% oxygen administered via a nonrebreather mask at a high flow rate (12-15 L/min) and subcutaneous or intranasal sumatriptan. Oxygen is highly effective, rapid-acting, and has a favorable side effect profile. Oral medications like ibuprofen have too slow an onset of action for the rapid and severe nature of a cluster headache. IV ketorolac may provide some relief but is not considered first-line. Propranolol is a prophylactic medication for migraines, not an acute treatment for cluster headaches.
Question 16
A 62-year-old woman presents with recurrent episodes of excruciating, electric shock-like pain on the left side of her face. The pain lasts for only a few seconds at a time but occurs in volleys. It is often triggered by light touch, such as applying makeup or brushing her teeth. Her neurologic examination is completely normal.
Which of the following is the most appropriate initial pharmacologic treatment for this condition?
- Carbamazepine (correct answer)
- Amitriptyline
- Naproxen
- Sumatriptan
Explanation: This patient's symptoms are classic for trigeminal neuralgia, a neuropathic pain disorder affecting the trigeminal nerve. It is characterized by paroxysms of severe, lancinating pain in the distribution of one or more branches of the nerve, triggered by innocuous stimuli. The first-line medical treatment for trigeminal neuralgia is the anticonvulsant carbamazepine. Amitriptyline is used for other types of neuropathic pain but is not first-line here. Naproxen and sumatriptan are ineffective for this condition.
Question 17
A 34-year-old woman presents to the urgent care clinic with a severe, unilateral, pulsating headache that began 3 hours ago. She rates the pain as 8/10 and reports associated nausea and photophobia. She has a history of similar headaches that occur 2-3 times per month. She has already taken a dose of ibuprofen at home with no relief. Her medical history is unremarkable, and she is not pregnant. Vital signs are stable.
Which of the following is the most appropriate next step in management?
- Administer subcutaneous sumatriptan (correct answer)
- Prescribe prophylactic propranolol
- Order a non-contrast CT scan of the head
- Administer intravenous morphine
Explanation: This patient is experiencing an acute, moderate-to-severe migraine attack that has failed to respond to a simple analgesic (ibuprofen). Triptans, such as sumatriptan, are first-line abortive therapy for such attacks. Propranolol is a prophylactic medication and is not used for acute treatment. A CT scan is not indicated as the headache presentation is typical for her known migraine disorder and there are no red flag symptoms. Opioids are generally avoided for migraine management due to the risk of dependence and medication overuse headache.
Question 18
A 71-year-old woman is evaluated in the emergency department after an episode of transient, painless, monocular vision loss in her left eye, which she described as a "curtain falling down." The episode lasted about 5 minutes and her vision has since returned to normal. Her medical history includes hypertension and smoking. A non-contrast head CT is unremarkable.
In addition to starting antiplatelet therapy, which of the following is the most important next diagnostic test?
- Lumbar puncture
- Carotid duplex ultrasonography (correct answer)
- Electroencephalogram (EEG)
- Funduscopic examination with fluorescein angiography
Explanation: Transient monocular vision loss (amaurosis fugax) is most commonly a symptom of a transient ischemic attack (TIA) due to atherosclerosis of the ipsilateral internal carotid artery. An embolus from a carotid plaque travels to the retinal artery, causing temporary ischemia. Therefore, the most critical next step is to evaluate for carotid artery disease with a carotid duplex ultrasound. This will identify any significant stenosis that may require surgical or endovascular intervention to prevent a future stroke. An EEG is for seizure evaluation, and a lumbar puncture is not indicated.
Question 19
An 81-year-old man presents with a syncopal episode that occurred while he was walking up a flight of stairs. His wife reports that he suddenly collapsed without warning and was unresponsive for about 20 seconds. He had no seizure-like activity and recovered quickly without confusion. He denies any prodromal symptoms. His medical history includes hypertension and dyslipidemia. Physical examination reveals a grade 3/6 late-peaking systolic ejection murmur at the right upper sternal border that radiates to the carotid arteries.
The patient's syncope is most likely due to which of the following?
- Orthostatic hypotension
- Vasovagal response
- Ventricular arrhythmia
- Aortic stenosis (correct answer)
Explanation: Exertional syncope in an elderly patient is a major red flag for a cardiovascular cause, specifically a fixed outflow obstruction. The physical examination finding of a late-peaking systolic ejection murmur is classic for severe aortic stenosis. In this condition, cardiac output cannot increase sufficiently to meet the metabolic demands of exercise, leading to decreased cerebral perfusion and syncope. Orthostatic hypotension occurs with changes in posture, and vasovagal syncope usually has a prodrome and a specific trigger, neither of which is present here. While an arrhythmia is possible, the combination of exertional syncope and the classic murmur makes aortic stenosis the most likely etiology.
Question 20
A 66-year-old man with a history of hypertension, type 2 diabetes mellitus, and hyperlipidemia suddenly developed slurred speech and right arm weakness while eating breakfast. His wife called emergency services immediately. By the time the ambulance arrived 15 minutes later, his symptoms had completely resolved. In the emergency department, his vital signs are stable and his neurologic examination is entirely normal.
What is the most likely diagnosis?
- Hemiplegic migraine
- Focal seizure
- Transient ischemic attack (correct answer)
- Hypoglycemic episode
Explanation: This patient presents with a classic history for a transient ischemic attack (TIA): the acute onset of focal neurologic deficits (dysarthria, arm weakness) that resolve completely within a short period (typically less than one hour), in a patient with multiple vascular risk factors. A hemiplegic migraine is less likely at this age of onset and is typically associated with a headache. A focal seizure may present with similar deficits, but a postictal state is common and resolution is not usually this rapid. Hypoglycemia would typically cause more global neurologic symptoms (e.g., confusion, altered consciousness) rather than focal deficits.