MCQs on Headaches

Written by Dr. James Whitfield (MBBS, FRACGP) – General Practitioner

Question 1

Anna, a 34-year-old office worker, presents with a 3-month history of intermittent headaches. She describes the pain as a dull, bilateral pressure or tightness, often described as a “band around the head.” The headaches are not associated with nausea, vomiting, photophobia, or phonophobia. They usually occur toward the end of the workday and improve with rest. Neurological examination is unremarkable.

What is the most appropriate initial management?

A) Amitriptyline
B) Sumatriptan
C) Ibuprofen
D) MRI of the brain
E) Beta-blocker

Correct Answer: C) Ibuprofen

Explanation:
Anna’s symptoms are consistent with a tension-type headache (TTH), the most common type of primary headache. Key features include bilateral, non-pulsatile, pressing or tightening pain, often described as a “band-like” discomfort, with mild to moderate intensity, and no aggravation by physical activity. Importantly, associated symptoms like nausea, vomiting, photophobia, or phonophobia are absent. The headache often occurs at the end of the day, linked to stress or poor posture.

For episodic TTH, the first-line management is simple analgesia, such as ibuprofen or paracetamol, combined with non-pharmacological strategies like stress reduction, good posture, regular sleep, and exercise. These approaches are both effective and safe for occasional use.

Why the other options are incorrect:

A) Amitriptyline: This is used as a prophylactic treatment for chronic TTH (headaches ≥15 days/month). It is not indicated for initial management of episodic TTH.
B) Sumatriptan: This is a serotonin receptor agonist used in the treatment of migraine, particularly with moderate to severe attacks or those unresponsive to simple analgesia. It is not effective for TTH.
D) MRI of the brain: Neuroimaging is not indicated in patients with a typical history of TTH and a normal neurological examination. Imaging is reserved for atypical headaches or when red flags are present (e.g., sudden onset, neurological deficits, systemic symptoms).
E) Beta-blocker: These are used for migraine prophylaxis, not for TTH. They have no proven benefit in TTH, especially not as an acute treatment.

Question 2

Sophie, a 29-year-old teacher, presents with a history of recurrent headaches for the past year. She describes the pain as throbbing and unilateral, typically located in the right temporal region. The headaches last around 6–8 hours, occur about twice a month, and are moderate to severe in intensity. They are often accompanied by nausea, photophobia, and phonophobia. The attacks worsen with physical activity, and she often has to lie down in a dark room. There are no preceding visual symptoms. Neurological examination is normal.

What is the most appropriate acute treatment for her headaches?

A) Amitriptyline
B) Ibuprofen
C) Sumatriptan
D) Ergotamine
E) Beta-blocker

Correct Answer: C) Sumatriptan

Explanation:
Sophie presents with classic features of migraine without aura, previously called “common migraine.” Typical features include unilateral, throbbing pain, nausea, photophobia, and phonophobia, with attacks that last between 4–72 hours and worsen with routine physical activity.

For moderate to severe attacks, or when simple analgesics fail, triptans such as sumatriptan are the first-line acute treatment. These 5-HT1B/1D receptor agonists are effective at relieving both headache and associated symptoms.

Why the other options are incorrect:

A) Amitriptyline: Used as prophylaxis, not for acute attacks.
B) Ibuprofen: Suitable for mild migraine but less effective in moderate to severe attacks, like Sophie’s.
D) Ergotamine: Older treatment for migraine, now less favored due to side effects and lower efficacy compared to triptans.
E) Beta-blocker: Used for migraine prophylaxis, not for acute management.

Question 3

James, a 38-year-old man, presents with excruciating headaches that have occurred daily for the past two weeks. Each attack lasts around 45 minutes and occurs at the same time every evening. The pain is severe, sharp, and unilateral, centered behind his left eye. During the attacks, he experiences tearing, nasal congestion, and ptosis on the same side. He is restless and unable to sit still during the pain. Neurological exam is normal.

What is the most appropriate acute treatment for his headache attacks?

A) Oral sumatriptan
B) Intranasal lidocaine
C) Oxygen therapy
D) Prednisolone
E) Ibuprofen

Correct Answer: C) Oxygen therapy

Explanation:
James is experiencing cluster headaches, a type of trigeminal autonomic cephalalgia. These headaches are characterized by recurrent, strictly unilateral, severe orbital or temporal pain, typically short-lasting (15–180 minutes), and often occurring in clusters over weeks. They are associated with autonomic symptoms (lacrimation, rhinorrhoea, ptosis, conjunctival injection) and restlessness, which is in contrast to migraines where patients prefer to lie down.

High-flow oxygen (100% oxygen at 10–15 L/min via a non-rebreather mask) for 15–20 minutes is the first-line emergency treatment and can rapidly abort an attack.

Why the other options are incorrect:

A) Oral sumatriptan: Oral formulations work too slowly; subcutaneous sumatriptan can be used but oxygen remains first-line.

B) Intranasal lidocaine: Has some efficacy but is less effective and not first-line.

D) Prednisolone: Used for prophylaxis, especially to shorten the cluster period, not for aborting acute attacks.

E) Ibuprofen: Generally ineffective for the severity and rapid onset of cluster headache attacks.

Previous Next

1. Neurology Module

1.1 Cerebrovascular Disorders

1.2 Cranial Nerves

1.3 Spinal Cord

1.4 Peripheral Nerves

1.5 Headaches

1.6 Seizure Disorders

1.7 Movement Disorders

1.8 Neuroimaging

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