12/4/2016

BMJ OnExamination Assessment : REF10526 : REF10526

Work Hard - MRCP Part 2 Written

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Exam Themes December 2004

Work hard progresses you systematically through the case problems giving you questions from all topics relevant to the current exam

in a random pattern; this encourages you to answer as many questions as possible, testing your knowledge on multiple topics.

1943/ 1956 questions answered

Question 1943 of 1956

A 51-year-old man was referred to the acute medical intake with a two week history of severe pain around his right eye.
The pain had started without any apparent precipitating event and had woken him from his sleep. He described the pain as severe and 'boring' and
radiated upwards over the right frontal and temporal region. The pain was not constant, but seemed to start every evening and persist for periods of 20
minutes to over an hour. The headaches were associated with watering of his right eye and a blocked left nostril. There was no past history of similar
episodes and no other past history of note.
On examination he was alert and orientated with a Glasgow coma scale score of 15/15. His blood pressure was 125/75 mmHg. He was afebrile and
there was no neck stiffness. The right eye was red with conjunctival injection and mild oedema of the eyelid. There was a partial right sided ptosis and
miosis.
Which of the following therapeutic options is most likely to alleviate his symptoms?
(Please select 1 option)
Aspirin
Carbamazepine
Indomethacin
Oxygen 100% FiO2

Correct

Verapamil
The most likely diagnosis is cluster headache (migrainous neuralgia).
This is characterised by recurrent episodes lasting 15-180 minutes of unilateral periorbital pain with associated autonomic features. Cluster headaches
can occur at any age, but are most common in age 20-50 years; there is a strong male preponderance (10:1).
The pain is described as severe and boring and radiates up over the frontotemporal region and/or down to the jaw, neck or shoulder. There is frequently
accompanying miosis with or without a Horner's syndrome. The ipsilateral eye is often red and watery; there is often associated rhinorrhoea or a
blocked ipsilateral nostril.
Oxygen 100% (6-8 L/min) often provides relief within 10 minutes.
Sumatriptan may also be used in the acute attack. Ergotamine, methysergide, verapamil and prednisolone have been used as prophylaxis once the
acute attack has resolved.
Vasodilators (alcohol, nitrates, calcium channel blockers) may precipitate attacks during the acute period, but not in remission.
The main differential is between cluster headaches and chronic paroxysmal hemicrania (CPH; which is treated with indomethacin).
Features that distinguish CPH are
Shorter duration of attacks (2-45 mins)
Increased frequency of attacks
Female preponderance and
Selective response to treatment with indomethacin.

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BMJ OnExamination Assessment : REF10526 : REF10526

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Score: 59.94%
Total Answered: 322

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