Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So if you're ready, let's jump right in. 

A 27-year-old otherwise well woman complains of recurrent headache that occurs every 1‒2 weeks and lasts up to 24 hours. During headache, she reports sudden onset of unilateral pulsating pain, nearly always on the left side of the head that is accompanied by photophobia, phonophobia, and mild nausea without vomiting. Her first headache occurred when she was approximately 12 years old.  Her neurological exam is within normal limits. This clinical scenario most consistent with: 
 
A. Cluster headache  
B. Tension-type headache  
C. Intracranial lesion  
D. Migraine without aura 

 Where do you start?  

 First, determine what kind of question this is. This is a diagnosis question where we're being asked to consider what kind of headache this patient has. Next, we're going to determine the probabilities. And based on the patient's symptoms, history, risk category. What's the most likely diagnosis? As I've mentioned in prior podcasts, and I mentioned in the Fitzgerald Review course, common diseases occur commonly, the most common reason for recurring headache is primary headache, a condition that involves a genetic predisposition to certain headache types and often triggered by environmental and other influences. In other words, there's no specific neurological abnormality, such as a space occupying intracranial lesion or the like that's triggering this cephalgia. The cephalgia is head pain.  

 The two most common primary headaches are migraine and tension type. We'll cover each of these headaches and their characteristics while going over the answers to the question. And a few comments about assessing the person with primary headache and important clinical considerations. Between any primary headache, the neuro exam is normal. During primary headache, the only acceptable variations in the neuro exam is photophobia and or phonophobia. 

 The majority of primary headache types, as this patients describes it, are, quote, the same headache over and over and over again. She is telling you, since she was 12, she had these headaches. This is actually one of the most reassuring clinical findings in headache. As headache associated with a neuro abnormality or a type of a secondary headache, likely, the neuro exam would be progressively abnormal. Even the absence of headache and the headaches will vary as time goes on. With female birth gender assignment the onset of primary headaches is often corresponds with menarche or the onset of the menses. Therefore, hearing that her headaches started when she was 12 is something consistent with headache onset at menarche.  

 And menarche, for most females will be between the ages of nine and 11. Let's take a look at the question again and also break down the answers. To recap, a 27 year old otherwise, well-woman complains of recurrent headache that occurs every 1 to 2 weeks and lasts up to 24 hours. During headaches, she reports sudden onset of unilateral, pulsating pain, nearly always on the left side that is accompanied by photophobia, phonophobia, and mild nausea without vomiting. Her first headache occurred when she was about 12 years old. Her neuro exam is within normal limits. This clinical scenario is most consistent with: 

 A. Cluster headache.  

 Well, let's take a look at this, cluster headache is actually a type of a primary headache, but with cluster headache (often abbreviated CH) the pain is typically unilateral, as she says, but usually the cluster is behind one eye and is accompanied by lacrimation and rhinorrhea. The pain is usually described as severe to the point where this is sometimes actually called the suicide headache, where the person suffering with this headaches thinks of self-harm in order to stop the pain. Cluster headaches usually lasts for less than 3 hours and are sometimes as brief as 30 minutes, but that's an excruciating 30 minutes. And the first headache usually occurs between the ages of 20 to 30 years.  

This is the only primary headache type found more commonly in males, though it's thought to be underdiagnosed in females. As you can see, this patient's presentation, since there's no lacrimation, no rhinorrhea, no pain behind the eye reported, wrong time for onset of first headache is not consistent with cluster headache. And by the way I'll add one more piece of information here: Cluster headaches are called cluster because they tend to occur in clusters a lot of times around season change. A person will have 2 to 3 weeks of cluster headache and then the headaches are quiescent for a number of months.

B. Tension type headache.

With tension type headache the pain is usually described as pressure tight and bilaterally — often with photophobia or phonophobia, but not with both. As previously noted, tension type headache (TTH) typically first manifests in female around menarche. While that is noted in the patient in this question, none of the other characteristics of the headache are consistent with tension type headache. Therefore, that is not the correct answer.  

Answer C. Intracranial lesion.  

A headache associated with an intracranial lesion would be considered to be a secondary headache. With secondary headaches, there's an identifiable underlying cause for the headache. A number of points in this scenario would lead us away from considering the diagnosis of any secondary headache. And this includes the length of time that the patient has had this headache. She's had the headache off and on for more than 15 years. The fact that she's had the same headache over and over again, as well as the normal neuro exam. While headache is not commonly reported with intracranial lesion, this secondary headache type is most often found at either end of the life span, with the majority being noted in the under five year olds and the over 60 year olds. This, of course, is not the correct answer.  

 Option D. Migraine without aura.   

This is, of course, the correct answer. Her presentation is classic for migraine without aura, which is the most common migraine form. Estimated that about 90% of people with migraine have migraine without aura. The characteristics of this headache include unilateral, pulsating pain, usually with both photophobia and phonophobia, often with nausea and occasionally with vomiting. In other words, the patient reports the same headache over and over and over again. Family history of migraine is often reported. That isn’t mentioned in this scenario, but she is presenting with classic migraine without aura. Keep in mind, on the NP boards, you're going to most often be tested on classic presentation of disease.  

 Key takeaway: The diagnostic process of any disease requires a careful analysis of the patient history and clinical presentation with the anticipation of findings these conditions in the most common risk groups.  

 Thank you for listening to NP Certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast. And for more NP resources, visit FHEA.com.