Headaches: Clinical

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Headaches: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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A 20-year-old woman comes to the clinic due to debilitating headaches for the past two months. She recently started college, and has been under a lot of stress due to the amount of work. Her medical history is significant for generalized anxiety disorder. She rates the pain as a 5 on a 10-point scale, and describes it as “tightness around her head”. Physical examination shows tenderness over the trapezius muscles bilaterally. Which of the following is most likely to benefit this patient in the long term?  


We’ve all had them. Headaches can be debilitating, and they occur when any of the pain-sensitive structures in the head and neck are stimulated. These include the meninges, blood vessels, nerves, and muscles.

Headaches can be classified into primary and secondary headaches. Primary headaches include tension, migraine, and cluster headaches, whereas secondary headaches are those that are due to another underlying disorder.

When an individual has a headache, especially if it feels different from their usual headaches, it’s important to think through causes of secondary headaches to avoid missing something important or life-threatening.

The mnemonic “SNOOP”, without the “D-O-double G”, summarizes some of the red flags.

“S” is for systemic symptoms like fever or weight loss.

“N” is for neurological symptoms, like weakness, sensory deficits, or vision loss.

The first “O” is for a new or sudden onset headache.

The second “O” is for other associated conditions, like trauma.

The “P” stands for progression or pattern, such as a headache that is worsening in severity or frequency.

Any of these findings warrant further investigation like brain imaging with a CT scan, or MRI, and in some cases a lumbar puncture.

Some clinical features may point towards a specific diagnosis, some of which may be life-threatening!

For example, if the headache develops suddenly, and feels like a 10 out of 10 in terms of pain right at its onset, or if it’s called “the worst headache of my life”, then it might be a subarachnoid hemorrhage. And it’s typically caused by rupture of an intracranial aneurysm.

Now, if someone has a sudden headache after a trauma, and it radiates down one side of the neck and is associated with Horner syndrome then it could be due to a carotid or vertebral artery dissection. This is also associated with pulsatile tinnitus which is a pulsating ringing sensation in the ears. If left untreated, the dissection could extend into the intracranial vessels, leading to a stroke.


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