Correct Answers to MODULE 2: Secondary Headache Disorders in Primary Care
Pre-Post Test Questions (Correct Answer is Bold)
1. Red flags for a secondary headache disorder are warning signs for other more ominous causes for headache (eg. brain tumors, subarachnoid hemorrhage, carotid dissection and dural venous thrombosis). Which of the following is “not” a red flag for a secondary headache disorder?
a. New onset of headache over age 50
b. New onset headache in those with immunosuppression, cancer or HIV
c. Headaches with severe intractable vomiting
d. Headaches worse with different positions such as lying down or standing up
e. Headaches with papilledema
f. Headaches with abnormal neurological signs or symptoms
g. Sudden onset headache
Explanation: The answer is c. Severe intractable vomiting can occur with migraine and is not listed as a red flag for secondary headache disorders. The others are all red flags for secondary headache disorders.
2. The most appropriate initial imaging study for a patient with a thunderclap headache is:
a. MRI of the head without contrast
b. MRI of the head with and without contrast
c. Non contrast CT of head
d. CT of head with and without contrast
Explanation: The correct answer is c. A thunderclap headache is a medical emergency and the patient should be sent to the emergency room immediately for further evaluation. A non-contrast CT is the diagnostic test of choice in the ER for several reasons. It is readily available in the ER and if done within 6 hours of the onset of the thunderclap headache then it has greater than a 95% sensitivity for identifying subarachnoid hemorrhage.
3. An MRI of the head with and without contrast (gadolinium) is indicated to rule out secondary headache disorders in all of the following clinical situations with the exception of?
a. Suspicion for meningeal carcinomatosis
b. Suspicion for brain metastases
c. Suspicion for Brain abscess
d. Orthostatic headaches
e. Subacute or chronic headache disorders that require neuroimaging
Explanation: The correct answer is e. The American Headache Society recommends that an MRI of the head without contrast to be performed in those with subacute or chronic headache disorders that require neuroimaging. The other disorders require
4. You see a person in the office with a “sudden onset” headache. You are concerned they could have a thunderclap headache, which can be caused by subarachnoid hemorrhage, carotid dissection, intracranial hypotension and others. A thunderclap headache is defined as a headache that reaches peak intensity within:
a. 1 minute
b. 5 minutes
c. 30 minutes
d. 1 hour
e. 1 day
Explanation: The correct answer is a. A thunderclap headache is a headache that reaches peak intensity in less than one minute.
5. Suspicion for any of the below diseases represents an indication for lumbar puncture with the exception of:
a. Temporal arteritis
c. Meningeal carcinomatosis
d. Idiopathic intracranial hypertension
Explanation: The correct answer is a. Temporal arteritis is diagnosed by a temporal artery biopsy. A lumbar puncture should be considered with the suspicion for the other diseases.