Headache - FITZ

Question 1

10. A 40-year-old man presents with a 5-week history of recurrent headaches that awaken him during the night. The pain is severe, lasts about 1 hour, and is located behind his left eye. Additional symptoms include lacrimation and nasal discharge. His physical examination is within normal limits. This clinical presentation is
    most consistent with:
    A. migraine without aura.
    B. migraine with aura.
    C. cluster headache.
    D. increased intracranial pressure (ICP).

Answer 1

C. cluster headache.

Question 2

11. A 22-year-old woman presents with a 3-year history
    of recurrent, unilateral, pulsating headaches with
    vomiting and photophobia. The headaches, which
    generally last 3 hours, can be aborted by resting in a
    dark room. She can usually tell that she is going to
    get a headache. She explains, “I see little ‘squiggles’
    before my eyes for about 15 minutes.” Her physical
    examination is unremarkable. This presentation is
    most consistent with:
    A. tension-type headache.
    B. migraine without aura.
    C. migraine with aura.
    D. cluster headache.

Answer 2

C. migraine with aura.

Question 3

12. Indicators that a headache can be the presenting symptom of a serious illness and may require neuroimaging
    include all of the following except:
    A. headaches that occur periodically in clusters.
    B. increasing frequency and severity of
    headaches.
    C. headache causing confusion, dizziness, and/or lack
    of coordination.
    D. headache causing awakening from sleep.

Answer 3

A. headaches that occur periodically in clusters.

Question 4

13. Prophylactic treatment for migraine headaches includes the use of:
A. amitriptyline.
B. ergot derivative.
C. naproxen sodium.
D. clonidine.

Answer 4

A. amitriptyline.

Question 5

14. Among the following beta blockers, which is the least effective in preventing migraine headache?
A. acebutolol
B. metoprolol
C. atenolol
D. propranolol

Answer 5

A. acebutolol

Question 6

15. Antiepileptic drugs useful for preventing
    migraine headaches include all of the following
    except:
    A. divalproex.
    B. valproate.
    C. lamotrigine.
    D. topiramate.

Answer 6

C. lamotrigine.

Question 7

16. Evidence supports the use of all of the following
    vitamins and supplements for migraine prevention
    except:
    A. butterbur.
    B. riboflavin.
    C. feverfew.
    D. ginkgo biloba.

Answer 7

D. ginkgo biloba.

Question 8

17. You are examining a 65-year-old man who has a
    history of acute coronary syndrome and migraine.
    Which of the following agents represents the best
    choice of acute headache (abortive) therapy for this
    patient?
    A. verapamil
    B. ergotamine
    C. acetaminophen
    D. sumatriptan

Answer 8

C. acetaminophen

Question 9

18. A 45-year-old man experiences rapidly progressing
    migraine headaches that are accompanied by significant gastrointestinal (GI) upset. Appropriate acute headache (abortive) treatment includes all of the following
    except:
    A. injectable sumatriptan.
    B. dihydroergotamine nasal spray.
    C. oral naproxen sodium.
    D. zolmitriptan nasal spray.

Answer 9

C. oral naproxen sodium.

Question 10

19. With migraine, which of the following statements
    is true?
    A. Migraine with aura is the most common form.
    B. Most migraineurs are in ongoing healthcare for
    the condition.
    C. The condition is equally common in both men
    and women.
    D. The pain is typically described as pulsating.

Answer 10

D. The pain is typically described as pulsating.

Question 11

20. In tension-type headache, which of the following
    is true?
    A. Photophobia is seldom reported.
    B. The pain is typically described as “pressing” in
    quality.
    C. The headache is usually unilateral.
    D. Physical activity usually makes the discomfort
    worse.

Answer 11

B. The pain is typically described as “pressing” in

quality.

Question 12

21. Risk factors for cluster headaches include all of the
following except:
A. being older than 65 years of age.
B. heavy alcohol use.
C. heavy tobacco use.
D. male gender.

Answer 12

A. being older than 65 years of age.

Question 13

22. Treatment options in cluster headache include the
    use of:
    A. nonsteroidal anti-inflammatory drugs (NSAIDs).
    B. oxygen.
    C. the triptans.
    D. all of the above therapies.

Answer 13

D. all of the above therapies.

Question 14

23. Which of the following oral agents has the most rapid analgesic onset?
    A. naproxen (Naprosyn®)
    B. liquid ibuprofen (Motrin®, Advil®)
    C. diclofenac (Voltaren®)
    D. enteric-coated naproxen (Naproxen EC®)

Answer 14

B. liquid ibuprofen (Motrin®, Advil®)

Question 15

24. The mechanism of action of triptans is as:
    A. a selective serotonin receptor agonist.
    B. a dopamine antagonist.
    C. a vasoconstrictor.
    D. an inhibitor of leukotriene synthesis.

Answer 15

A. a selective serotonin receptor agonist.

Question 16

25. Limitations of use of butalbital with acetaminophen
    and caffeine (Fioricet®) include its:
    A. energizing effect.
    B. GI upset profile.
    C. high rate of rebound headache if used frequently.
    D. excessive cost.

Answer 16

C. high rate of rebound headache if used frequently.

Question 17

26. The use of neuroleptics such as prochlorperazine
    (Compazine®) and promethazine (Phenergan®) in
    migraine therapy should be limited to less than three
    times per week because of their:
    A. addictive potential.
    B. extrapyramidal movement risk.
    C. ability to cause rebound headache.
    D. sedative effect.

Answer 17

B. extrapyramidal movement risk.

Question 18

27. Which of the following statements about ergotamines is false?
    A. They are effective for tension-type headaches.
    B. They act as 5-HT1A and 5-HT1D receptor
    agonists.
    C. They have a potential vasoconstrictor effect.
    D. They should be avoided in the presence of coronary artery disease.

Answer 18

A. They are effective for tension-type headaches.

Question 19

28. With appropriately prescribed headache prophylactic therapy, the patient should be informed to expect:
    A. virtual resolution of headaches.
    B. no fewer but less severe headaches.
    C. approximately 50% reduction in the number
    of headaches.
    D. that lifelong therapy is advised.

Answer 19

C. approximately 50% reduction in the number

of headaches.

Question 20

29. A 48-year-old woman presents with a monthly
    4-day premenstrual migraine headache, poorly
    responsive to triptans and analgesics, and
    accompanied by vasomotor symptoms (hot flashes).
    The clinician considers prescribing all of the following
    except:
    A. continuous monophasic combined oral contraceptive.
    B. phasic combined oral contraceptive with a
    7-day-per-month withdrawal period.
    C. low-dose estrogen patch use during the
    premenstrual week.
    D. triptan prophylaxis.

Answer 20

B. phasic combined oral contraceptive with a

7-day-per-month withdrawal period.

Question 21

30. A first-line prophylactic treatment option for the
prevention of tension-type headache is:
A. nortriptyline.
B. verapamil.
C. carbamazepine.
D. valproate.

Answer 21

A. nortriptyline.

Question 22

31. A 47-year-old woman experiences occasional migraine with aura and reports partial relief with zolmitriptan.
    You decide to add which of the following to augment
    the pain control by the triptan?
    A. lamotrigine
    B. gabapentin
    C. naproxen sodium
    D. magnesium

Answer 22

C. naproxen sodium

Question 23

32. A 68-year-old man presents with new onset of
    headaches. He describes the pain as bilateral frontal
    to occipital and most severe when he arises in the
    morning and when coughing. He feels much better
    by midafternoon. The history is most consistent with
    headache caused by:
    A. vascular compromise.
    B. increased intracranial pressure (ICP).
    C. brain tumor.
    D. tension-type with atypical geriatric presentation

Answer 23

B. increased intracranial pressure (ICP).

Question 24

33. Systemic corticosteroid therapy would be most
    appropriate in treating:
    A. tension-type headache.
    B. migraines occurring on a weekly basis.
    C. intractable or severe migraines and cluster
    headaches.
    D. migraines occurring during pregnancy.

Answer 24

C. intractable or severe migraines and cluster

headaches.

Question 25

34. When evaluating a patient with acute headache, all of the following observations would indicate the absence of a more serious underlying condition except: A. onset of headache with exertion, coughing, or sneezing. B. history of previous identical headache. C. supple neck. D. normal neurological examination results.

Answer 25

A. onset of headache with exertion, coughing, or | sneezing.

Question 26

``` 35. Common secondary headache causes include all of the following except: A. brain tumor. B. intracranial bleeding. C. intracranial inflammation. D. cluster headache. ```

Answer 26

D. cluster headache.

Question 27

36 to 38. Match the female:male ratio for each type of primary headache listed: A. 1:3 to 1:8 B. 3:1 C. 5:4 36. Tension-type headache

Answer 27

C. 5:4

Question 28

36 to 38. Match the female:male ratio for each type of primary headache listed: A. 1:3 to 1:8 B. 3:1 C. 5:4 37. Migraine without aura

Answer 28

B. 3:1

Question 29

36 to 38. Match the female:male ratio for each type of primary headache listed: A. 1:3 to 1:8 B. 3:1 C. 5:4 38. Cluster headache

Answer 29

A. 1:3 to 1:8

Question 30

39 to 43. Indicate the appropriate course of action (head CT scan, head magnetic resonance imaging [MRI], or neither) for each of the following patients: 39. A 45-year-old man who presents with a sudden, abrupt headache. Upon questioning, he appears somewhat confused with decreased alertness to his surroundings.

Answer 30

CT scan

Question 31

39 to 43. Indicate the appropriate course of action (head CT scan, head magnetic resonance imaging [MRI], or neither) for each of the following patients: 40. A 48-year-old woman with a history of breast cancer who presents with 3-month history of progressively severe headache, and bulging optic disk.

Answer 31

MRI

Question 32

39 to 43. Indicate the appropriate course of action (head CT scan, head magnetic resonance imaging [MRI], or neither) for each of the following patients: 41. A 24-year-old man who presents in the emergency department (ED) following a motor vehicle accident. He exhibits confusion and falls in and out of consciousness.

Answer 32

CT scan

Question 33

39 to 43. Indicate the appropriate course of action (head CT scan, head magnetic resonance imaging [MRI], or neither) for each of the following patients: 42. A 57-year-old woman with a prior history of a brain tumor that was removed 8 years ago. She complains of headaches that have been increasing in frequency and intensity over the past month.

Answer 33

MRI

Question 34

39 to 43. Indicate the appropriate course of action (head CT scan, head magnetic resonance imaging [MRI], or neither) for each of the following patients: 43. A 37-year-old man diagnosed with cluster-type headache that is alleviated with high-dose NSAIDs.

Answer 34

Neither

Question 35

44. In counseling a patient who experiences migraines, you recommend all of the following lifestyle changes to minimize the risk of triggering a headache except: A. avoiding eating within 1–2 hours of a.m. awakening. B. limiting exposure to cigarette smoke. C. avoiding trigger physical activities. D. implementing strategies to reduce stress.

Answer 35

A. avoiding eating within 1–2 hours of a.m. awakening.

Question 36

``` 45. A 37-year-old woman complains of migraine headaches that typically occur after eating in restaurants. Potential triggers that can influence the onset and severity of migraine symptoms include all of the following except: A. cheese pizza. B. pickled or fermented foods. C. freshly baked yeast products. D. baked whitefish. ```

Answer 36

D. baked whitefish.

Question 37

Headache “Red Flags” (SNOOP Mnemonic)

Answer 37

* Systemic symptoms | * Fever, weight loss, or secondary headache risk factors such as HIV, malignancy, pregnancy, anticoagulation

Question 38

Headache “Red Flags” (SNOOP Mnemonic)

Answer 38

* Neurological signs, symptoms * Any newly acquired neurological finding including confusion, impaired alertness or consciousness, nuchal rigidity, hypertension, papilledema, cranial nerve dysfunction, abnormal motor function

Question 39

Headache “Red Flags” (SNOOP Mnemonic)

Answer 39

* Onset * Sudden, abrupt, or split-second; the “thunderclap” headache * Onset of headache with exertion, sexual activity, coughing, sneezing * Suggests subarachnoid hemorrhage, sudden-onset increased intracranial pressure

Question 40

Headache “Red Flags” (SNOOP Mnemonic)

Answer 40

* Onset (age at onset of headache) | * Older (>50 years) and younger (<5 years)

Question 41

Headache “Red Flags” (SNOOP Mnemonic)

Answer 41

* Previous headache history * First headache in adult ≥30 years * Primary headache pattern usually established in youth/young adult years * New onset of different headache * Change in attack frequency, severity, or clinical features including progressive headache without headache-free period

Question 42

``` Potential Lifestyle, Health Status, or Medication Triggers Influencing the Onset or Severity of Migraine Symptoms: A Comprehensive Headache Treatment Plan Includes Minimizing or Eliminating These Triggers Whenever Possible ```

Answer 42

``` Menses, ovulation, or pregnancy Birth control/hormone replacement (progesterone) therapy Illness of virtually any kind, whether acute or chronic Intense or strenuous activity/exercise Sleeping too much/too little/jet lag Fasting/missing meals Bright or flickering lights Excessive or repetitive noises Odors/fragrances/tobacco smoke Weather/seasonal changes High altitudes Medications Stress/stress letdown ```

Question 43

``` Potential Dietary Triggers Influencing the Onset or Severity of Migraine Symptoms: A Comprehensive Headache Treatment Plan Includes Minimizing or Eliminating These Triggers Whenever Possible ```

Answer 43

Sour cream Ripened cheeses (cheddar, Stilton, Brie, Camembert) Sausage (bologna, salami, pepperoni, summer sausage, hot dogs) Pizza Chicken liver pâté Herring (pickled or dried) Any pickled, fermented, or marinated food Monosodium glutamate (MSG) (soy sauce, meat tenderizers, seasoned salt) Freshly baked yeast products, sourdough bread Chocolate Nuts or nut butters Broad beans, lima beans, fava beans, snow peas Onions Figs, raisins, papayas, avocados, red plums Citrus fruits Bananas Caffeinated beverages (tea, coffee, cola) Alcoholic beverages (wine, beer, whiskey) Aspartame/phenylalanine-containing foods or beverages

Question 44

Cluster headaches

Answer 44

are most common in middle-aged men, particularly men with heavy alcohol and tobacco use

Question 45

Cluster headaches

Answer 45

Sometimes called the “suicide headache” because of the severity of the associated pain, cluster headache occurs periodically in clusters (hence its name) of several weeks, with associated lacrimation and rhinorrhea.

Question 46

Cluster headache treatment

Answer 46

reduction of triggers, such as tobacco and alcohol use, and initiation of prophylactic therapy and appropriate abortive therapy (triptans, high-dose NSAIDs, and high-flow oxygen)