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Probing Headaches: A Diagnostic Challenge Quiz
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What differentiates migraine from underlying intracranial pathology that may require neuroimaging, like tumors, abscesses, aneurysms, or hemorrhages? Test your skills with this 5-question quiz.
Question 1
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Answer D.90%
About 90% of headaches are thought to be primary, the most common of which is tension-type headache. Other primary headache disorders include migraine, trigeminal neuralgias, and other primary headache disorders like cold-stimulus headache, primary exercise headache, and external pressure headache.
Dodick DW. Pearls: headache. Semin Neurol. 2010;30:74-81.
Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
Question 2
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Answer D. Pattern change
The SNOOP algorithm has been proposed identify red flags that may differentiate secondary from primary headache. The letters in the algorithm stand for:
S: Systemic symptoms of disease
N: Neurologic symptoms
O: Onset recently or suddenly
O: Older age of onset
P: Pattern change from previous history, including progressive headache with loss of headache free days; precipitated by Valsalva maneuver; postural aggravation; papilledema
Dodick DW. Pearls: headache. Semin Neurol. 2010;30:74-81.
Question 3
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Answer C. Pulsatile
The POUND acronym has been proposed to differentiate migraine from underlying intracranial pathology that may require neuroimaging, like tumors, abscesses, aneurysms, or hemorrhages. One study found that meeting 4 of the 5 criteria in the acronym yields a likelihood ratio of definite or possible migraine of 24.
The letters in the mnemonic stand for:
P: Pulsailte quality
O: Duration 4 to 72 hours
U: Unilateral location
N: Nausea or vomiting
D: Disabling in intensity
Detsky ME, McDonald DR, Baerlocher MO, et al. Does this patient with headache have a migraine or need neuroimaging? JAMA. 2006;296(10):1274-83.
Question 4
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Answer A. At least 3 attacks
The International Classification of Headache Disorders-3 (ICHD-3) diagnostic criteria for migraine without aura includes the following:
• At least 5 attacks
• Attacks lasting 4 to 72 hours
• Headache with 2 or more of the following: unilateral pain, pulsating quality, moderate/severe pain intensity
• Aggravated by, or causing avoidance of, routine physical activities
• At least one of the following during an attack: nausea and/or vomiting OR photophobia/ phonophobia
• Not better explained by another ICHD-3 diagnosis
Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38:1-211.
Question 5
Answer C. Photophobia
The IDMigraine test is a simple, three question screening test that can be used once secondary headache has been ruled out. The test includes three questions covering nausea, photophobia, and headache-related functional disability. A positive screen requires two out of three symptoms to be present. When tested in routine primary care, the IDMigraine showed a sensitivity of 81%, specificity of 75%, and positive predictive value of 93%.
Lipton RB, Dodick D, Sadovsky R, et al. A self-administered screener for migraine in primary care: The ID Migraine validation study. Neurology. 2003;61:375-382.
