AKT question of the week: neurology

by Administrator 13. April 2010 10:53

A 29-year-old engineer comes to see you about his headaches. He has been getting a severe headache every night for the past three weeks. He says that the pain is "unbearable" and often wakes him from sleep.

He says that he wakes, often before midnight, with an intense pain around his right eye and that the pain radiates back to the whole head. It never seems to affect the left side of his head but he has noticed that he gets a runny nose during attacks. He says that he has had similar attacks a couple of times a year for the past few years but they usually subside after a couple of weeks.

He is a smoker and normotensive. Pupils are both equal and reactive. There is no abnormality testing cranial nerves and a quick neurological exam of the upper limbs is normal. His fundi appear normal but you note that he is extremely short sighted. There are no rashes visible.

After reading an article about migraine in a women's magazine he thought he should consult you about treatment.

What is the most likely diagnosis?

  1. Acute Herpes zoster infection
  2. Cluster headaches
  3. Chronic sinusitis
  4. Migraine
  5. Ramsay Hunt syndrome
  6. Space occupying lesion
  7. Temporomandibular joint dysfunction

 

Answer and explanation

Cluster headaches

Candidates have demonstrated poor performance in the clinical management of common causes of headache in previous exams, so it's reasonable to expect that you might be tested on this again.

This patient is describing cluster headaches. These headaches are commoner in men that women and tend to affect men from their late 20s onwards. Of all the causes of headaches, cluster headaches seem to result in the most severe discomfort and the pain is usually unilateral and located behind one eye.

They are termed cluster headaches because they tend to occur in clusters lasting several weeks, several times a year. Patients will often experience headaches within a few hours of falling asleep and they may have associated symptoms of rhinorrhoea. His myopia is a red herring and has no bearing on the diagnosis.

As we have stated in similar questions, the history is of much greater help in establishing a diagnosis for patients presenting with headache than the examination. The examination of patients presenting with headache serves mainly to assist in the reassurance of a worried patient, because it rarely adds to the diagnosis.

Patients with cluster headache may exhibit signs of rhinorrhoea, lacrimation or even ptosis if examined during an attack, but examination is usually normal when attending in surgery. However, it is wise, at the very least, to check the blood pressure and fundi of patients presenting with a headache. You should also consider palpating the head and neck for areas of tenderness.

This question also highlights another important issue - that patients sometimes reach their own conclusions about diagnoses and that these are not necessarily correct. Beware the patient attending for "antibiotics for my urine infection" or "tablets for my indigestion" without having ascertained the diagnosis for yourself!

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AKT | MRCGP | OnExamination

Comments

4/13/2010 11:28:24 AM #

Huda

This is a typical history for cluster headaches.
Male patient between 25 to 50, smoker, with headache of distinct pattern: unilateral sever ocurring periodically, with active periods interrupted by spontaneous remissions, associated with ipsilateral eye pain+_ redness+_lacrimation, rhinorrhea or nasal stuffiness...


Huda U.A.E. |

4/13/2010 7:29:20 PM #

Editor

Thank you for your comments, Huda. What do you think about some of the other diagnoses? This patient seems to be worried about migraine. What would you tell him about migraine and how would you explain that you feel that an alternative diagnosis is more likely (if it is)?

Editor United Kingdom |

4/13/2010 7:54:14 PM #

Huda

migrain is more common to females,nature of headache is usually unilateral and pulsating associated with nausea,vomiting,photophobia not eye pain, phonophobia...in addition some patients experiecnce aura before the onset of the headache.
It is less likely to be SOL,as there is no signs of increase ICP
It is not option 1 or 5 as the condition is chronic.

Huda U.A.E. |

4/13/2010 8:28:46 PM #

Editor

That's a comprehensive response, Huda. You're clearly knowledgeable about common causes of headache and, if you're sitting the AKT exam, this will put you in good stead should they ask about this in the exam. As an aside, space occupying lesions are notoriously elusive particularly in primary care where patients can present in the early stages, as I'm sure that you are aware. An absence of signs is reassuring and makes it less likely, but does not completely rule out the possibility, as I'm sure you appreciate. The RCGP have tested candidates in their management of common causes of migraine in the past. How would you approach a patient with migraine? What would be your first line choice of treatment for an acute attack or for prophylaxis? What features would lead you to decide to institute prophylaxis when presented with a patient suffering from migraine?

Editor United Kingdom |

4/14/2010 3:02:29 PM #

Huda

Many thanks to you Dr. Preest(Editor). Dealing with Migrain managment I think that it is  related to severity of the pain during the acute attack where the abortive treatment could range from NSAID to Opiates. Whats important in the prophylaxis is avoiding any triggering factors plus the medications as Beta blockers,tricyclic antidepressants... this medical prophylaxis should be offered to those with recurrent disabling attacks(>2 attacks per month)...
By the way, I will set for MRCP part I in May 11, what do u advice me??

Huda U.A.E. |

4/14/2010 7:26:58 PM #

Editor

Thanks for your contribution, Huda and good luck with your MRCP part 1. Although my area of expertise relates to primary care examinations rather than MRCP, as general advice I would say that you should practice as many questions as possible so that you are familiar with the format and improve examination technique. I would also say that it is important to identify any weak areas and concentrate on those, rather than simply reading material that appeals. Forgive me if this sounds like a blatant advert (it's not, I promise) but BMJ Onexamination also have an MRCP revision resource that you might find useful. Our questions and answers in "Questions dissected" are geared towards a more primary care perspective and that may be counterproductive for you in some circumstances because our spread of diagnoses and investigations will be more geared towards general practice rather than secondary care clinicians. That said, I hope you find this pilot useful and the very best of luck with your forthcoming exam.

Editor United Kingdom |

4/13/2010 6:27:09 PM #

Steve Short

I'm going to go for cluster headaches. The unilateral nature, regular timing of onset (with ability to wake from sleep), location of pain by eye initially go towards this. The autonomic feature of rhinrrhoea, and I'm pretty sure nicotine can be a trigger/have  relation also push me even more towards this. Previous attacks would sway me away from SOL. The severity of pain would also go with clusters as opposed to sinusitis. 3 weeks would be a significant length for some of the other options before showing other signs.

Steve Short United Kingdom |

4/13/2010 8:09:42 PM #

Editor

Welcome back, Steve and thank you for taking the time to comment on this week's question. As with last week's question, we have selected a question this week where candidates have performed badly in previous AKT examinations. The RCGP have said that candidates have exhibited poor knowledge of the management of common causes of headaches in the primary care setting, so it's important that you are familiar with this in case they decide to test candidates again. We'll give the answer along with the author's explanation at the end of the week. The best way to approach this (and any other single best answer question) is to look at the history first and then, without looking at the options, decide on the most likely diagnosis. Your first impression is usually correct. Then look at the options to see if your answer is there. The RCGP have stated that more than one option may be plausible with these questions and the skill is often in being able to come up with the most likely diagnosis. From the feedback that we get from candidates at BMJ Onexamination, we find that some candidates get bogged down in the minutiae of alternative diagnoses and then get confused or angry (with us!) that more than one answer may apply. Try not to do this. Your approach to this question, as with last week's anaphylaxis question, is correct. You have focused on what you feel is the most likely diagnosis and picked out features in the history that support your decision. I'm not going to say if this is correct yet, but your approach to this question is correct. What do you think about the significance (or not) of the myopia?

Editor United Kingdom |

4/13/2010 8:59:18 PM #

Steve Short

To be honest, I'm not fully sure of the significance of the severe myopia, particularly with reference to any of the possible answers to this question. I feel there may be a link between headaches and uncorrected myopia, but feel it may be added in as a "red herring" for this question. I'm curious to find out whether there is relevance or not...

Steve Short United Kingdom |

4/13/2010 9:44:20 PM #

Editor

All will be revealed at the end of the week. Thanks for responding.

Editor United Kingdom |

4/13/2010 8:06:44 PM #

James Case

Have to agree with Steve. Typical history, in practice would probably entertain most of those diagnoses but for the AKT... cluster headaches.

James Case United States |

4/13/2010 8:20:02 PM #

Editor

Many thanks for your contribution, James. A consensus seems to be forming here. It's important with the AKT to focus on the question (as you have done) - they've asked for a diagnosis and you should provide just that without worrying about any other issues such as investigations or treatment. However, as there seems to be a consensus forming here - to broaden the discussion a little - how would you manage this patient? If you were asked about the management of cluster headaches in the exam, your answer should be representative of nationally published guidelines and consensus view. (I notice that you're based in the USA. If you're sitting the MRCGP AKT exam, consensus opinion and guidelines would be UK based). What would be your advice to this patient and what would be your first choice of treatment?

Editor United Kingdom |

4/14/2010 9:01:58 AM #

K.pirabaanandanan

It's cluster heaadche beyond any doubt.

K.pirabaanandanan |

4/14/2010 2:35:56 PM #

Editor

Many thanks for your comment. How would you manage this condition?

Editor United Kingdom |

4/14/2010 10:58:13 AM #

magid

Cluster headaches just pops out at me with this question. the nature, duration, number of attacks annually plus the fact that he is a male and smoker in the appropriate age group. may i say that looking too much at the options before answering may make you hesitate but the first (and almost always right) impression must win! in practice though i would investigate the patient further especially to rule out SOL, just to be on the safe side.

magid Saudi Arabia |

4/14/2010 2:35:01 PM #

Editor

Your comment about not looking at options first is absolutely correct and this applies to most questions in this format. Thanks for your comment, Magid

Editor United Kingdom |

4/19/2010 2:50:50 PM #

magid

thank you for the comprehensive answer and advice but i would like to ask about the management of this patient as the question is presented i.e it says he comes with complains of headaches but not with one, so if the answer options included both high flow oxygen and sumatriptan and verapamil which would be more correct?

magid Saudi Arabia |

4/19/2010 7:50:15 PM #

Editor

Thank you Magid. For the purposes of examination questions it's really important to address the question being posed. So, if you given this question in an exam, you must do what is asked and concentrate your thoughts on the most likely diagnosis. With regard to treatment (and I emphasise that your knowledge of the treatment is not being tested here), your answer to the examination question very much depends on how the question is posed. As a general statement, I would approach this case by firstly establishing the patients ideas, concerns and expectations. I would try to explain the nature of cluster headaches and address any fears they may have about their headaches. The general consensus in the UK with regard to medication for an acute attack would be sumatriptan. However there is some evidence that early treatment during a cluster with a prophylactic medicine such as verapamil can help (an alternative would be prednisolone). Very often, the symptoms are so severe and patients so distressed that referral to a specialist may be necessary to confirm the diagnosis and the NHS Clinical knowledge summary recommends that patients with suspected cluster headache are referred urgently for specialist opinion.
However, I stress that your knowledge of treatment is not being tested in this question and you should concentrate your thoughts in an examination setting on the question being posed. Without wishing to advertise our own site, we have a number of questions which address the issue of treatment of common headaches at BMJ Onexamination.com because we feel that it is important that candidates sitting the exam are knowledgeable in this area, particularly as it has been registered as a concern in previous examination feedback.

Editor United Kingdom |

4/20/2010 10:17:52 AM #

Editor

Many thanks for your further comment about this question, Magid and for the details of the actual AKT question that appeared in the MRCGP exam. We have not published your subsequent comment because it gives details of an actual MRCGP AKT question. However, in answer to your observations about the RCGP AKT question, as appeared in your exam, you will find the answer by looking at the CKS website (NHS clinical summaries) and the BASH website (look at their guidance about cluster headache). You will find the answer to the question there. We have decided not to publish details of that actual MRCGP question, in case RCGP should decide to test candidates on it again (and having highlighted it as an area of deficiency, it's quite possible that they will).

Editor United Kingdom |

4/24/2010 4:50:48 PM #

Dr saima

The same question came into MRCP-2 exam april 2010 and thay ask about the initial treatment.answers were
opioid
sub cut.sumitriptan
nasal decongestant
reassurance
I choose sub cut sumitriptan
Is it a correct choice

Dr saima Saudi Arabia |

4/24/2010 9:01:19 PM #

Editor

Yes it is and I agree with your answer. For the acute treatment of cluster headache subcut sumatriptan is the treatment of choice. Of the options you have listed, you have selected the correct answer. Thanks for your contribution, Dr Saima and good luck with your exam results. Don't worry about this particular question - I'm sure that you got this question right.

Editor United Kingdom |

4/26/2010 8:06:15 PM #

magid

thank you very much for your feedback, the links are quite helpful. looking forward for more such questions

magid Saudi Arabia |

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About the editor

Dr Geraint Preest
BSc MB BCh DRCOG MRCGP
Primary Care Editor BMJ Onexamination
GP Principal Pencoed Medical Centre Pencoed