Board Review Questions of the Week – Headache Disorders

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Free headache disorders board review questions sample from Med-Challenger.

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This week’s case-based question:

A 45-year-old woman presents with sudden-onset severe headache, 2 episodes of vomiting, and photophobia without neurologic deficit. She tells you that 10 days ago she was evaluated for these exact symptoms and underwent non-contrast computed tomography (CT) of the head followed by an unremarkable lumbar puncture (LP). However, those findings were negative. She then saw a neurologist in follow-up who subsequently diagnosed her with reversible cranial vasoconstriction syndrome (RCVS).

What is your next step in evaluation today?

Answer Options

Treat with intravenous metoclopramide 10 mg and discharge her home.
Obtain repeat CT of the head and follow-up with LP if CT findings are nondiagnostic.
Obtain magnetic resonance imaging (MRI) of the brain with magnetic resonance angiography (MRA) and magnetic resonance venography (MRV).
If a pregnancy test is negative, then prescribe her sublingual ergotamine 2 mg.

And the answer is …

Correct Answer:

Obtain magnetic resonance imaging (MRI) of the brain with magnetic resonance angiography (MRA) and magnetic resonance venography (MRV).

Educational Objective:

Describe the appropriate workup of headache most likely caused by vasospasm.

Key Point:

RCVS is a cause of recurrent thunderclap headaches and may cause ischemic or hemorrhagic stroke.


Your next step should be to obtain MRI of the brain with MRA and MRV.

RCVS is a cerebral arteriopathy characterized by segmental areas of vasoconstriction of large- and medium-sized vessels. This diagnosis must be differentiated from subarachnoid hemorrhage and other hemorrhagic strokes, cerebral venous thromboembolism, carotid artery dissection, and pituitary apoplexy. Conceptually, the diagnostic process is similar to that in patients with chest pain, when cardiac ischemia due to reversible coronary artery vasospasm in normal coronary arteries versus irreversible ischemia due to coronary blockage must be differentiated. (In the brain, rupture of the vessel must also be considered in addition to blockage.)

RCVS presents with brief headaches that are truly severe and reach a maximum intensity of pain (10 out of 10 [worst pain ever] on pain scales) within several seconds that then resolves to a dull, post-event headache. Attacks can be singular or occur at multiple times during any given day.

Neurovascular imaging should be pursued in patients with recurrent thunderclap headache. Because RCVS is associated with risk of stroke, brain edema, or other cerebral morbidity, it is reasonable to admit patients at risk so they can be observed for a few days.

Triptans and ergotamines can exacerbate vasoconstriction and stroke, so they are relatively contraindicated for treatment.


Kwiatkowski T, Friedman B. Headache disorders. In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:1265-1277.

Singhal A. Reversible cerebral vasoconstrictive syndromes. Revised November 16, 2017. Accessed June 7, 2018.

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