Pain and Headache Question Bank

A 36-year-old female is seen in the emergency department for a headache which has been persistent and pervasive for many weeks. She has no past medical history, denies recreational drugs, nasal sprays or supplements. She describes a sharp and stabbing pain that is very severe over the right temporal and supraorbital areas causing restlessness. Her right eye can droop and tear during the episode.  It is occurring on average of 20 times per day and can lasts up to 30 minutes. Time to peak pain occurs in under 10 minutes. 

In the emergency department she has a CT-brain, which is normal. 

Her neurological examination is normal and Glasgow Coma Score (GCS) is 15. 

What is the likely diagnosis?

A 52-year-old female presents to the outpatients’ department with a 4-month history of daily right-sided frontotemporal headaches with nasal stuffiness and sweating, nausea and occasional photophobia. She describes a continuous deep aching which is typically mild-moderate in intensity, punctuated by less frequent, more severe exacerbations that last between 30 minutes and 3 days. She is restless during the exacerbations and she thinks they can be triggered by alcohol. 

Her neurological examination, including fundoscopy, is normal as is her MRI-brain. 

An indomethacin trial is successful.

What is the likely diagnosis?

A 62-year-old man is admitted with frequent headaches. He describes a severe sharp and stabbing sensation over the right eye with association conjunctival injection. He reports they occur multiple times a day in short bursts lasting seconds rendering it difficult to note the exact daily frequency. In between the sharp jolts, which last seconds, there is occasional interictal pain. Occasionally, tactile stimuli can provoke an attack. He has a childhood history of migraines that resolved in his twenties. 

Which of the following treatments is most likely to be successful?

A 38-year-old male presents to outpatient with recurrent throbbing over his left eye which weeps and becomes “bloodshot” and has woken him from sleep at night for the past 10 weeks. The attacks are occurring 8 times per day lasting up to 3 hours but typically last an hour. The onset is abrupt and peaks between 5-15 minutes. He paces around the room during the episodes. He has had a similar bout 12 months ago that lasted several weeks. He has not noticed any clear triggers.

He has a past medical history of migraines and takes amitriptyline. He drinks minimal alcohol and has a 20 pack-year smoking history. 

His examination is normal including visual acuities and pupillary reflexes and you suspect a primary headache disorder. 

Which of the following is most likely?

A 58-year-old female with a past medical history of migraine and hypertension presented to the hospital with a two-week history of headache and nausea. She described a frontal band-like headache. 

Her neurological examination was normal and blood pressure 145/85mmHg. She is afebrile. Kernig and Brudzinski signs are negative and there is no papilloedema.

Her neuroimaging is shown below (left = T2 coronal, right = T1 coronal with gadolinium).

What is the likely cause of her headaches?

A 42-year-old female is seeing you in the Outpatient Department in April with a holocephalic headache present since December 12^th (4-months ago). She remembers the day vividly as the pain was most intense and she had a severe bout of flu-like symptoms. Since this time, she has been experiencing pressure-like pain with some associated photophobia. The headaches typically last for more than 4 hours. 

She has no past medical history and takes paracetamol every two- to three days on average during a 30-day period. 

Her neurological examination is normal including crisp optic discs. Blood pressure is 132/86mmHg. 

An MRI-brain performed near the onset of symptoms revealed a small arachnoid cyst with no features of raised intracranial pressure. 

What is the likely cause for her headaches?

A 48-year-old female is seen in outpatient clinic with persistent pain over a discrete small region on the parietal/scalp region on the right. It has been present for 6 months and is of moderate intensity with no worsening on bending, coughing or sneezing. She also describes intermittent jolt-like pains in the same region that initially lasted for seconds but have increased to minutes in duration. She denies any jaw claudication symptoms but there is tenderness over the aforementioned region. 

She has a past medical history of rheumatoid arthritis and is maintained on methotrexate. 

Her neurological examination reveals some tenderness over the scalp region but nothing else. Her blood pressure is 124/72mmHg. 

Her MRI-brain is normal and blood results are pending. 

What is the likely diagnosis?

A 42-year-old female presents to outpatient clinic with jolt-like pains over the vertex. She reports pain predominantly on the right but the site can vary. The lancinating pains last for seconds and can occur one to multiple times per day. She denies any autonomic symptoms. She has no other past medical history.

Her brain imaging and neurological examination are normal. Her blood pressure is 135/85mmHg. 

What is the likely diagnosis?

A 32-year-old female with migraines is being reviewed in your outpatient Neurology clinic. She is currently on amitriptyline 40mg ON and has been for 6 months. Previous migraine preventatives include propranolol and candesartan, which were unsuccessful. She takes paracetamol 11-14 days of the month and triptans on 6 days. 

She brings a headache diary with her. This records 8 migraine days and 17 headache days during the month. Her current treatment has provided a 20% reduction in her headaches. 

Which of the following is the most appropriate next treatment option?

Which of the following methods is NOT recommended for the prevention of menstrual migraine?

A 34-year-old woman is referred to the headache clinic for management of migraine. Since the age of 16 she has suffered stereotyped unilateral, pounding headaches associated with photophobia, phonophobia and vomiting. There are no identifiable triggers and she has no aura. Headaches occur once and occasionally twice each week and last 12-24 hours. She is unable to work or partake in activities of daily life during headaches.

She uses sumatriptan for the most severe headaches, around twice per month, and high-dose aspirin typically once per week. She has tried amitriptyline and nortriptyline, neither of which were tolerated. Propranolol caused symptomatic postural hypotension.

Medical history is remarkable for gastro-oesophageal reflux disease, kidney stones and depression. Other than acute analgesia, she takes vitamin D supplements, omeprazole 20mg OD and sertraline 100mg OD.

Which of the following would you recommend?

A 42-year-old woman is referred to Neurology from the ENT department after their investigations failed to reveal a cause of her symptoms.

A year ago she underwent an uncomplicated extraction of a premolar tooth. Six weeks later she developed fluctuating aching pain over the ipsilateral cheek and jaw, which is now a constant, deep ache. She underwent an orthopantomogram, which was normal, and an MRI and MRA brain, which were also normal. 

She describes a constant, severe, dull pain affecting her left cheek and jaw. She thinks it may be exacerbated by chewing but there are no other triggers. She has not noticed lacrimation, rhinorrhoea, facial sweating or flushing, nausea, vomiting or photophobia. There is no diurnal variation. She reports her vision can be blurred at times. 

On examination, pupils are equal and reactive to light and discs appear normal. She has a refractive error that corrects with pinhole. Eye movements and facial movements are normal. Facial sensation is intact, as is the corneal reflex. Bulbar function is normal.

What is the first-line treatment for this condition?

A 45-year-old woman returns to clinic for a review. She was diagnosed with trigeminal neuralgia 6 months prior and started treatment with carbamazepine but was hospitalised 1 week later with fever, arthralgia and widespread targetoid lesion. She was diagnosed with Steven-Johnson syndrome and carbamazepine was switched to gabapentin. She continued to report severe episodic facial pain so phenytoin was substituted 3 months prior to her appointment with you. 

In clinic she reports persistent, lightning-like left-sided facial pain over her zygoma, exacerbated by touch and cold, occurring 5-10 times per day. She takes 300mg phenytoin once daily. 

You request an MRI and MRA, which does not reveal any cause for her symptoms.

What is the next step in her management?

A 25-year-old woman is referred to the headache clinic for counselling regarding genetic testing for hemiplegic migraine. She has suffered from occasional migraine with visual aura since the age of 15. She describes stereotyped episodes of fatigue followed by a gradually expanding scintillating scotoma that lasts around an hour, followed by severe unilateral headache, photophobia, nausea and vomiting. 

Over the past 3 years she has had 3 episodes associated with mild left-sided weakness that resolved spontaneously after 48 hours.

Her father, currently aged 56 years, has suffered from migraine with aura since age 17. They are characterised by side-locked headaches associated with nausea, vomiting and photophobia and around half are also associated with left-sided weakness.

Her mother has no relevant medical conditions. Her sister has mild learning difficulties and hearing impairment.

Genetic testing of the proband and her father confirms familial hemiplegic migraine type 2.

Which of the following statements regarding the diagnosis is false?

A 72-year-old woman is referred to the Neurology clinic by her GP for management of severe facial pain. Five years ago she was diagnosed with left-sided trigeminal neuralgia, refractory to carbamazepine and lamotrigine and underwent balloon compression of the Gasserian ganglion, which was initially effective.

She describes 2 months of constant, burning pain with superimposed electric-shock-like sensations affecting her left temporal and periorbital region, exacerbated by even the most delicate cutaneous stimulation.

On examination, there is a region of exquisite sensitivity to fine touch above and around the left eye with patchy regions of numbness when the area is explored with a neurotip.

What is the likely diagnosis?

A 51-year-old male is referred to the general Outpatient Clinic with a persistent headache. He has experienced daily or near daily headache for the last 10 years. Originally, his headaches were episodic with severe unilateral orbital or maxillary pain lasting around 4 hours. Now, he describes a bilateral, severe throbbing pain, sometimes associated with nausea and photophobia. He experiences exacerbations of pain lasting several hours at least twice a week. 

He is being treated by his GP for migraine and for the last few years has been established on a regime of pizotifen 1.5mg daily and he takes sumatriptan 50mg for each severe exacerbation.

On examination he has a normal systemic and neurological examination.

Regarding the initial evaluation of this patient, which of the following is most likely to be correct?

A 25-year-old woman has a 6-year history consistent with migraine without aura. She is taking propranolol 60mg twice daily as prophylaxis but continues to experience debilitating headaches once or twice per month. She is unable to take oral medication during attacks and is not keen on subcutaneous injections. She requests a trial of rizatriptan wafers for the acute attacks.

What advice should be given about the use of rizatriptan?

An 18-year-old male, originally from Japan, presents to the Outpatient Department with progressive headache and visual disturbance. He has a past medical history of type 1 diabetes, which is adequately controlled. He reports an increase in thirst and urination. He denies recreational drugs and there is no family history of headache or visual failure.

On examination, his BMI is 26kg/m², his blood pressure is 128/84mmHg and heart rate 72bpm. Neurological examination reveals corrected visual acuity of 6/24 on the right and 12/24 on the left with impaired colour vision. You note disc pallor bilaterally with the remainder of the examination normal. 

An MRI is performed (shown below). Post-contrast images (not shown) reveal vivid enhancement in the suprasellar and pineal region.

He is referred to the neurosurgical MDT and subsequent neuropathology reveals positive placental alkaline phosphatase (PLAP), c-kit, and OCT 3/4.

What is the diagnosis?

A 38-year-old male with chronic cluster headache enquires about preventative medication.

Which of the following are potential candidates?