Headaches: Pathology review

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Headaches: Pathology review



Headaches: Pathology review

USMLE® Step 1 questions

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USMLE® Step 1 style questions USMLE

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A 55-year-old woman comes to the office due to 2 months of episodic jaw pain. She describes sharp shooting, “shock like” pain over the left side of her jaw that typically lasts for a few seconds. She has noticed a few times that the pain has occurred while she was eating dinner, and once while she was brushing her teeth. Physical examination shows no abnormalities. The patient is started on the first line medication for her condition. During her one month follow-up appointment, she states that her symptoms have improved significantly, but she describes feeling some dizziness and instability. Which of the following is the mechanism of action of the medication being used by this patient?  


At the neurology department, there’s a 34-year old male, named Andrew, who came in due to headache. This is the first time he’s had a headache like this and described the pain as “the worst headache of his life”. Neurological examination reveals neck stiffness. His medical history is otherwise insignificant. Next to Andrew, there’s a 30-year old female, named Anna, who complains of recurrent episodes of unilateral, pulsating headaches that usually occur when she’s tired, and last approximately 6 hours each time. Her mother also suffers from similar episodes of headache. Finally, there’s a 40-year old male, named Evan, who has had recurrent attacks of excruciating headaches for the past two months. The pain is located behind his eye, typically occurs in the morning, and lasts for about one hour. He also has nasal congestion and lacrimation of the affected eye. He has no family history of similar episodes.

All three people suffer from headaches. A headache occurs 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 two types. The first are called primary headaches, and they’re more common. These are chronic or recurrent headaches and include tension headaches, migraines, and cluster headaches. Now, the second type are called secondary headaches, and these are acute headaches from a specific underlying cause like a serious head injury, infection, or a brain tumor.

Alright, now let’s take a closer look at the different types of primary headaches. Tension headaches are the most common type and they’re more common in females. On the exams, the classic description is a headache that is slowly-progressive, bilateral, tight, “band-like” headache with no other associated symptoms. Typically, they lasts from 30 minutes to up to a week, and is usually triggered by stress and dehydration. It is thought that these headaches are due to an increased sensitivity to pain due to the release of vasoactive neuropeptides like substance-P and calcitonin gene-related peptides. These headaches can be treated acutely by NSAIDs, and chronic pain can be treated with amitriptyline or other tricyclic antidepressants.


  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "CURRENT Diagnosis & Treatment in Family Medicine, Third Edition" McGraw Hill Professional (2010)
  4. "Vasodilation out of the picture as a cause of migraine headache" The Lancet Neurology (2013)
  5. "Does This Patient With Headache Have a Migraine or Need Neuroimaging?" JAMA (2006)
  6. "Tension-type headache" BMJ (2008)

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