96. A 22-year-old woman reports a scotoma progressing across her left visual field over the course of 30 minutes, followed by left hemicranial throbbing pain, nausea, and photophobia. Her brother and mother have similar headaches. Which of the following is present in this patient’s condition but not in common migraine?
a. Photophobia
b. Familial pattern
c. Visual aura
d. Hemicranial pain
e. Nausea
97. A 16-year-old woman has been having attacks of weakness, blurry vision, and loss of consciousness. The symptoms progress over 20-to-30 minutes, then begin to recede and are followed by a throbbing occipital headache. This patient’s symptoms are most likely due to which of the following?
a. Complex partial seizure
b. Common migraine
c. Basilar migraine
d. Transient ischemic attack
e. Orthostatic hypotension
98. A 43-year-old woman describes lancinating pains radiating into the right side of her jaw. This discomfort has been present for more than 3 years and has started occurring more than once a week. The pain is paroxysmal and routinely triggered by cold stimuli, such as ice cream and cold drinks. She has sought relief with multiple dental procedures and has already had two teeth extracted. Multiple neuroimaging studies reveal no structural lesions in her head. Assuming there are no contraindications to the treatment, a reasonable next step would be to prescribe which of the following?
a. Clonazepam, 1 mg orally three times daily
b. Diazepam, 5 mg orally two times daily
c. Divalproex sodium, 250 mg orally three times daily
d. Indomethacin, 10 mg orally three times daily
e. Carbamazepine, 100 mg orally three times daily
99. A 23-year-old woman has had 1 week of worsening facial pain. She describes it as an intense shooting pain that comes and goes. It is present only on her right face. Which of the following is most likely to be this patient’s underlying problem?
a. Multiple sclerosis
b. Tolosa-Hunt syndrome
c. Migraine
d. Anterior communicating artery aneurysm
e. Falx meningioma
100. A 39-year-old left-handed woman is being treated with carbamazepine for lancinating pain in her left face. The pain is paroxysmal, usually occurring without apparent reason, but seems sometimes to be brought on by a cold breeze. Both trigeminal neuralgia and atypical facial pain involve pain that may be which of the following?
a. Lancinating
b. Paroxysmal
c. Associated with anesthetic patches
d. Abolished with resection of the gasserian ganglion
e. Unilateral
101. A 26-year-old graduate student presents to the emergency room with a severe left-sided throbbing headache associated with nausea, vomiting, and photophobia. She has tried taking ibuprofen without relief. On further questioning, she relates that she has been having similar headaches three to four times per month for the past year. Her mother had a similar problem. Her examination is normal. Immediate therapy for this patient’s present headache might include which of the following drugs?
a. Sumatriptan
b. Nitroglycerine
c. Verapamil
d. Amitriptyline hydrochloride
e. Phenobarbital
102. A 16-year-old girl has been diagnosed with migraine headaches. She has identified some triggers and made lifestyle changes, but still has 14 headaches per month. Appropriate long-term management might include a prescription for daily use of which of the following medications?
a. Metoclopramide hydrochloride
b. Sumatriptan
c. Oral contraceptives (OCPs)
d. Amitriptyline hydrochloride
e. Ergotamine tartrate
103. A 32-year-old woman is being evaluated for headaches. They started about 6 months ago and occur a few times per week, lasting until she falls asleep. The pain is constant and focused at the front and back of the head. The pain is unrelated to position and tends to be worse later in the day. There is mild photophobia. Which of the following findings is most likely?
a. Slightly reduced neck range of motion and paracervical tenderness
b. Papilledema
c. Abnormal brain magnetic resonance imaging (MRI)
d. Abnormal brain computed tomography (CT)
e. Abnormal electroencephalogram (EEG)
Questions 104 to 108
For each clinical scenario, pick the diagnosis that best explains the clinical picture. Each lettered option may be used once, more than once, or not at all.
a. Classic migraine
b. Cluster headache
c. Common migraine
d. Trigeminal neuralgia
e. Sinusitis
f. Temporal arteritis
g. Vertebrobasilar migraine
h. Hemiplegic migraine
i. Atypical facial pain
j. Postherpetic neuralgia
104. A 22-year-old dance instructor routinely develops headaches on the weekend. The headaches are almost always limited to the right side of her head and centered about the right temple. She knows that a headache is coming because of changes in her vision that precede the headache by 20-to-30 minutes. She sees scintillating lights just to the left of her center of vision. This visual aberration then expands and interferes with her vision. The blind spot that it creates appears to have a scintillating margin. As the blind spot clears, the headache starts. It rarely lasts more than 1 hour, but is usually accompanied by nausea and vomiting.
105. A 29-year-old woman comes to the emergency room with facial pain of new onset. She has stabbing pains on the left side of her face just below her eye. These last less than 1 second at a time, but are so severe that she winces involuntarily with each pain. The pain seems to be triggered by drinking cold fluids. The only other problems she has noticed are clumsiness in her right hand and blurred vision in her right eye. Both of these have been present for more than 2 years and have not interfered with her normal activities.
106. A 35-year-old man has severe throbbing pain waking him from sleep at night and persisting into the day. This pain is usually centered about his left eye and appears on a nearly daily basis for several weeks or months each year. It occurs most prominently at night within a few hours of falling asleep and is associated with a striking personality change in which the man becomes combative and agitated. He never vomits or develops focal weakness.
107. A 76-year-old man develops a dull left-sided head pain with some radiation of the discomfort to the right side of the head. He has no nausea or vomiting with the pain, but has lost 10 lb over the previous 2 months. His erythrocyte sedimentation rate is 102 mm/h, and he is mildly anemic. An extensive investigation for malignancy reveals no signs of lymphoma, carcinoma, or leukemia.
108. An 81-year-old man with chronic lymphocytic leukemia develops pain and burning over the right side of his face. Within a few days, a vesiculopapular rash in the distribution of the first division of the trigeminal nerve appears. The vesicles become encrusted, and the burning associated with the rash abates. Within 1 month the rash has largely resolved, but the man is left with a dull ache over the area of the rash that is periodically punctuated by shooting pains. Imipramine 100 mg nightly helps reduce the intensity of the chronic pain.
Questions 109 to 111
For each clinical scenario, select the most likely diagnosis. Each lettered option may be used once, more than once, or not at all.
a. Carotid artery dissection
b. Pseudotumor cerebri
c. Glioblastoma multiforme
d. Thunderclap headache
e. Analgesic rebound headache
f. Paroxysmal hemicrania
g. Raeder syndrome
h. Intracranial hypotension
i. Posttraumatic headache
j. Aseptic meningitis
109. An obese 37-year-old woman has had a daily headache, worse in the morning, for 1 year. She has episodes of transient visual obscurations affecting each eye and also hears a pulsatile tinnitus. Examination is notable for bilateral papilledema. MRI is normal.
110. A 42-year-old man presents with a sudden and severe headache associated with nausea. The headache reaches maximal intensity within 5 seconds. He has no prior history of headache. Examination is unremarkable. CT and spinal fluid examination show no evidence of blood. He later admits that he had been engaged in sexual activity when the headache occurred.
111. A 29-year-old man relates that he has had recent headaches only when standing up. The headaches resolve quickly when he lies down and are accompanied by mild nausea. His examination is normal.