Absolutely — here’s a high‑yield set of USMLE‑style practice questions designed to reinforce the headache diagnostic algorithm you just learned. Each question is followed by the correct answer and a concise explanation so you can see exactly how the algorithm guides the reasoning.
A 45‑year‑old man develops a sudden, severe headache described as “the worst of his life.” He vomits once and arrives at the ED within 30 minutes. BP is 160/95. Neuro exam is normal.
Next best step?
A. MRI brain
B. Non‑contrast CT head
C. Lumbar puncture
D. ESR and CRP
E. Triptan therapy
Answer: B — Non‑contrast CT head
Why: Thunderclap onset = rule out subarachnoid hemorrhage. CT first; LP only if CT is negative.
A 22‑year‑old woman presents with headache, photophobia, fever, and neck stiffness. She is alert and oriented. No focal deficits.
Next best step?
A. MRI brain
B. Lumbar puncture
C. CT head → LP
D. Start triptans
E. ESR/CRP
Answer: B — Lumbar puncture
Why: Suspected meningitis without focal deficits → LP immediately. CT is only needed first if there are focal deficits, papilledema, or altered mental status.
A 63‑year‑old woman has new‑onset unilateral temporal headache and jaw pain when chewing. Vision is intermittently blurry.
Most appropriate initial test?
A. MRI brain
B. ESR and CRP
C. CT head
D. Temporal artery biopsy
E. Triptan therapy
Answer: B — ESR and CRP
Why: New headache >50 + jaw claudication → temporal arteritis. ESR/CRP are the first tests; biopsy confirms.
A 34‑year‑old man reports a headache that worsens when standing and improves when lying flat. He had a lumbar puncture 2 days ago.
Most likely diagnosis?
A. Migraine
B. Tension headache
C. Cluster headache
D. Low‑pressure (CSF leak) headache
E. Idiopathic intracranial hypertension
Answer: D — Low‑pressure headache
Why: Post‑LP positional headache = classic for CSF leak.
A 28‑year‑old woman has recurrent unilateral throbbing headaches with nausea and photophobia. They worsen with activity.
Most likely diagnosis?
A. Migraine
B. Tension headache
C. Cluster headache
D. Trigeminal neuralgia
E. Medication‑overuse headache
Answer: A — Migraine
Why: Unilateral + pulsatile + nausea + photophobia + worsened by activity = migraine.
A 40‑year‑old man has severe unilateral orbital pain lasting 45 minutes. His eye tears and his nose runs during attacks. He paces around the room.
Most likely diagnosis?
A. Migraine
B. Tension headache
C. Cluster headache
D. Acute glaucoma
E. Sinusitis
Answer: C — Cluster headache
Why: Short, severe unilateral pain + autonomic symptoms + restlessness = cluster.
A 50‑year‑old woman has daily headaches. She has been taking OTC analgesics almost every day for months. Neuro exam is normal.
Most likely diagnosis?
A. Chronic migraine
B. Tension headache
C. Medication‑overuse headache
D. Idiopathic intracranial hypertension
E. Temporal arteritis
Answer: C — Medication‑overuse headache
Why: ≥15 days/month + chronic analgesic use = rebound headache.
A 29‑year‑old obese woman presents with daily headaches and transient visual obscurations. Fundoscopy shows papilledema.
Next best step?
A. MRI brain + MRV
B. Lumbar puncture
C. CT head
D. ESR/CRP
E. Start triptans
Answer: A — MRI brain + MRV
Why: Papilledema → rule out mass or venous sinus thrombosis before LP.
A 32‑year‑old man describes a bilateral, band‑like headache that feels like pressure. No nausea or photophobia. Not worsened by activity.
Most likely diagnosis?
A. Migraine
B. Tension headache
C. Cluster headache
D. Sinusitis
E. Cervical radiculopathy
Answer: B — Tension headache
Why: Bilateral + pressure + mild/no associated symptoms = tension.
A 55‑year‑old man with a history of lung cancer presents with new headaches that worsen when lying down. Neuro exam shows mild ataxia.
Next best step?
A. MRI brain
B. CT head
C. ESR/CRP
D. LP
E. Triptans
Answer: A — MRI brain
Why: Cancer history + new headache + focal signs → rule out metastasis with MRI.
If you want, I can generate another set, make them more difficult, or turn these into a timed quiz to simulate exam pressure.
Great — let’s build on your momentum with a fresh set of high‑yield, exam‑style headache practice questions that reinforce the diagnostic algorithm. I’ll keep them sharp, realistic, and clinically useful.
A 30‑year‑old woman reports headaches preceded by flashing lights in her visual field. The headache is unilateral, throbbing, and associated with nausea.
Most likely diagnosis?
Answer: Migraine with aura
Why: Visual aura + unilateral throbbing + nausea = classic.
A 55‑year‑old man has progressive morning headaches and occasional vomiting. Neuro exam shows mild papilledema.
Next best step?
Answer: MRI brain
Why: Progressive headache + papilledema → rule out mass lesion.
A 40‑year‑old woman has facial pressure, purulent nasal discharge, and headache worsened by leaning forward.
Most likely diagnosis?
Answer: Acute sinusitis
Why: Positional worsening + sinus symptoms.
A 28‑year‑old man has a persistent headache 3 days after a mild head injury. He is alert and oriented.
Most likely diagnosis?
Answer: Post‑concussive headache
Why: Headache after mild TBI with normal neuro exam.
A 35‑year‑old woman reports headaches triggered by coughing and straining. No neurologic deficits.
Next best step?
Answer: MRI brain
Why: Valsalva‑triggered headaches → rule out Chiari malformation or posterior fossa lesion.
A 60‑year‑old man has severe unilateral headache, nausea, and a red, painful eye. Pupils are mid‑dilated and non‑reactive.
Most likely diagnosis?
Answer: Acute angle‑closure glaucoma
Why: Eye pain + red eye + fixed pupil + headache.
A 42‑year‑old man with HIV presents with headache, fever, and confusion. CT is normal.
Next best step?
Answer: Lumbar puncture
Why: Suspected meningitis/encephalitis → LP after CT rules out mass effect.
A 29‑year‑old obese woman has daily headaches and transient visual obscurations. Papilledema is present.
Most likely diagnosis?
Answer: Idiopathic intracranial hypertension (pseudotumor cerebri)
Why: Young obese woman + papilledema + visual symptoms.
A 70‑year‑old woman has new headaches, scalp tenderness, and jaw pain when chewing.
Most likely diagnosis?
Answer: Temporal arteritis (giant cell arteritis)
Why: Age >50 + jaw claudication + scalp tenderness.
A 38‑year‑old man has severe unilateral headaches lasting 20–40 minutes, occurring nightly for a week. His eye tears during attacks.
Most likely diagnosis?
Answer: Cluster headache
Why: Short, severe, unilateral, autonomic features, occurring in clusters.
If you want, I can create:
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Absolutely — here’s a third, more advanced set of headache‑diagnosis practice questions. These are designed to stretch your clinical reasoning, force you to integrate red‑flag logic, and distinguish subtle presentations that often appear on exams.
A 42‑year‑old woman develops a unilateral throbbing headache with nausea. Thirty minutes before the headache, she experienced right‑hand numbness and difficulty speaking. Symptoms resolved completely before the headache began. Neuro exam is normal.
Most likely diagnosis?
Answer: Migraine with aura (complex migraine)
Why: Fully reversible neurologic symptoms preceding headache → aura. Stroke deficits do not resolve fully within minutes.
A 36‑year‑old man with HIV (CD4 80) presents with headache, fever, and mild confusion. Fundoscopy shows no papilledema. CT head is normal.
Next best step?
Answer: Lumbar puncture
Why: Immunosuppressed + fever + headache → meningitis/cryptococcal infection must be ruled out. Normal CT → safe to LP.
A family of four presents with headache, dizziness, and nausea. Symptoms improve when they go outside.
Most likely diagnosis?
Answer: Carbon monoxide poisoning
Why: Multiple people + nonspecific headache + improvement outdoors.
A 50‑year‑old woman with untreated hypertension presents with severe headache and blurry vision. BP is 220/130. Fundoscopy shows cotton‑wool spots and papilledema.
Most likely diagnosis?
Answer: Hypertensive emergency with encephalopathy
Why: Severe BP + papilledema + neurologic symptoms.
A 29‑year‑old woman had a lumbar puncture 5 days ago. She now has a headache that is worse when lying down and improves when upright.
Most likely diagnosis?
Answer: Intracranial hypertension (not CSF leak)
Why: CSF leak headaches worsen when standing. Opposite pattern → consider intracranial hypertension.
A 48‑year‑old man has new‑onset headaches and episodes of déjà vu followed by confusion. Neuro exam is normal.
Next best step?
Answer: MRI brain
Why: Focal seizures + new headache → structural lesion until proven otherwise.
A 35‑year‑old man develops unilateral neck pain and headache after a minor car accident. He now has partial ptosis and miosis on the same side.
Most likely diagnosis?
Answer: Carotid artery dissection
Why: Pain + partial Horner syndrome after trauma.
A 26‑year‑old obese woman has daily headaches and pulsatile tinnitus. Fundoscopy shows papilledema. MRI is normal.
Next best step?
Answer: Lumbar puncture to measure opening pressure
Why: Diagnosis of IIH requires elevated opening pressure after imaging rules out mass.
A 40‑year‑old man develops a sudden, severe headache during intercourse. He has no neurologic deficits.
Next best step?
Answer: Non‑contrast CT head
Why: First‑time sex‑triggered thunderclap headache → rule out subarachnoid hemorrhage.
A 32‑year‑old woman, 2 weeks postpartum, presents with severe headache and focal seizures. Fundoscopy shows papilledema.
Most likely diagnosis?
Answer: Cerebral venous sinus thrombosis
Why: Postpartum hypercoagulability + headache + seizures + papilledema.
If you want, I can create:
Just tell me where you want to take this next.
Absolutely, Silverio — here comes a fourth set, crafted to be even more challenging, with trickier red‑flag logic, subtle mimics, and the kind of nuance that separates a good clinician from a great one. These are designed to push your diagnostic reasoning to the edge.
A 38‑year‑old woman develops recurrent thunderclap headaches over several days. She recently started taking pseudoephedrine for a cold. Neuro exam is normal. CT head is normal.
Most likely diagnosis?
Answer: Reversible cerebral vasoconstriction syndrome (RCVS)
Why: Recurrent thunderclap headaches + vasoactive drug exposure + normal CT.
A 52‑year‑old man presents with sudden severe headache, diplopia, and ptosis. He is hypotensive and appears acutely ill.
Most likely diagnosis?
Answer: Pituitary apoplexy
Why: Sudden headache + ophthalmoplegia + acute adrenal insufficiency signs.
A 33‑year‑old woman has a headache that improves when lying flat and worsens when upright. She denies recent procedures.
Next best step?
Answer: MRI brain with gadolinium
Why: Look for pachymeningeal enhancement → spontaneous CSF leak.
A 72‑year‑old woman has new headaches and shoulder stiffness. ESR is mildly elevated. No jaw claudication.
Most likely diagnosis?
Answer: Polymyalgia rheumatica with possible GCA overlap
Why: PMR + new headache → treat as GCA until proven otherwise.
A 29‑year‑old woman has unilateral headache and pain with eye movement. She reports decreased color vision. Fundoscopy is normal.
Most likely diagnosis?
Answer: Optic neuritis
Why: Pain with eye movement + decreased color vision = classic.
A 68‑year‑old man on warfarin presents with progressive headache and confusion. No history of trauma.
Most likely diagnosis?
Answer: Chronic subdural hematoma
Why: Anticoagulation + gradual symptoms, even without trauma.
A 45‑year‑old man has severe headache, fever, and maxillary sinus tenderness. He also has diplopia.
Most likely diagnosis?
Answer: Cavernous sinus thrombosis
Why: Sinus infection + cranial nerve palsy (III, IV, V1, V2, VI).
A 50‑year‑old woman presents with headache, nausea, and confusion. Labs show low sodium. She has no edema and normal vitals.
Most likely diagnosis?
Answer: SIADH causing hyponatremic encephalopathy
Why: Euvolemic hyponatremia → cerebral edema → headache.
A 60‑year‑old man with known prostate cancer has new headaches and nausea. CT head is normal.
Next best step?
Answer: MRI brain with contrast
Why: CT can miss small metastases, especially in posterior fossa.
A 41‑year‑old woman has unilateral headache and ptosis/miosis. No trauma. Pain radiates to the jaw.
Most likely diagnosis?
Answer: Carotid artery dissection
Why: Horner syndrome + unilateral head/neck pain, even without trauma.
If you want to push even further, I can create:
Just tell me where you want to go next.
Absolutely, Silverio — here comes Set #5, crafted to be brutal, subtle, and exam‑level tricky. These questions force you to integrate red‑flag logic, mimic‑recognition, and the kind of pattern‑matching that separates top scorers from everyone else.
Let’s push your diagnostic reasoning to the limit.
A 47‑year‑old woman presents with a thunderclap headache. CT head performed 12 hours after onset is normal. She is still photophobic and nauseated.
Next best step?
Answer: Lumbar puncture
Why: CT sensitivity for SAH drops sharply after 6 hours. Persistent symptoms → LP for xanthochromia.
A 62‑year‑old man with a chronic cough presents with headache, confusion, and serum sodium of 118. He is euvolemic.
Most likely diagnosis?
Answer: SIADH secondary to small‑cell lung cancer
Why: Euvolemic hyponatremia + lung mass → paraneoplastic SIADH → cerebral edema → headache.
A 33‑year‑old woman has daily headaches, transient visual obscurations, and horizontal diplopia. Fundoscopy shows papilledema.
Which cranial nerve is affected?
Answer: CN VI (abducens)
Why: Increased ICP stretches CN VI → lateral rectus palsy → horizontal diplopia.
A 29‑year‑old man has fever, headache, and new right‑arm weakness. CT shows a ring‑enhancing lesion.
Most likely diagnosis?
Answer: Brain abscess
Why: Fever + focal deficit + ring‑enhancing lesion = abscess, not tumor.
A 71‑year‑old woman has new headaches and transient monocular vision loss. ESR is normal.
Next best step?
Answer: Start steroids immediately
Why: ESR can be normal in GCA. Vision symptoms → treat first, biopsy later.
A 28‑year‑old woman at 34 weeks gestation presents with severe headache, visual changes, and a generalized tonic‑clonic seizure. BP is 170/110.
Most likely diagnosis?
Answer: Eclampsia
Why: Pregnancy + hypertension + seizure = eclampsia until proven otherwise.
A 45‑year‑old woman has unilateral headache, jaw pain, and ear fullness. Pain worsens with chewing. Neuro exam is normal.
Most likely diagnosis?
Answer: TMJ dysfunction
Why: Jaw pain + ear fullness + chewing‑related worsening.
A 60‑year‑old man with poorly controlled diabetes develops a headache and diplopia. His eye is “down and out,” but the pupil is normal.
Most likely diagnosis?
Answer: Diabetic CN III palsy (ischemic)
Why: Pupil‑sparing CN III palsy = microvascular ischemia.
A 55‑year‑old man presents with occipital headache, vertigo, and ataxia. He has hypertension and smokes. CT head is normal.
Next best step?
Answer: MRI brain (posterior fossa)
Why: CT often misses cerebellar strokes.
A 41‑year‑old man has severe headache, fever, and periorbital swelling. He has difficulty moving his eye laterally.
Most likely diagnosis?
Answer: Cavernous sinus thrombosis
Why: Sinus infection + ophthalmoplegia + fever = CST.
If you want to go even deeper, I can create:
Just tell me how hard you want to push next.
Silverio, you asked for Set #6, the one that’s pure board‑style curveballs — the kind of questions that make even seasoned clinicians pause. These are deliberately tricky, pattern‑breaking, and designed to test whether you truly own the headache algorithm.
Let’s get into it.
A 34‑year‑old woman has daily headaches and pulsatile tinnitus. MRI brain is normal. MRV shows subtle narrowing of the transverse sinuses. Fundoscopy shows papilledema.
Next best step?
Answer: Lumbar puncture to measure opening pressure
Why: Normal MRI does not exclude IIH. MRV narrowing is common. Diagnosis requires elevated opening pressure.
A 28‑year‑old woman develops headache, agitation, tremor, and diaphoresis after her sertraline dose was increased. She has hyperreflexia and clonus.
Most likely diagnosis?
Answer: Serotonin syndrome
Why: Headache + autonomic instability + neuromuscular hyperactivity.
A 37‑year‑old man has unilateral headache and severe eye pain. Pain worsens when he looks up or medially. Pupils are normal. No redness.
Most likely diagnosis?
Answer: Orbital myositis
Why: Pain with extraocular movements + normal pupils + no conjunctival injection.
A 49‑year‑old woman presents with acute severe vertigo, vomiting, and occipital headache. She cannot walk without support. CT head is normal.
Next best step?
Answer: MRI brain (posterior circulation)
Why: CT misses cerebellar strokes. Severe vertigo + gait instability + headache = posterior stroke until proven otherwise.
A 55‑year‑old man has headache, fever, and severe shoulder pain. ESR is elevated. No jaw claudication.
Most likely diagnosis?
Answer: Polymyalgia rheumatica with possible GCA involvement
Why: PMR + headache + fever → treat as GCA until ruled out.
A 62‑year‑old woman has brief, stabbing, electric‑shock pains on the right side of her face triggered by brushing her teeth. Neuro exam is normal.
Most likely diagnosis?
Answer: Trigeminal neuralgia
Why: Classic triggerable paroxysmal facial pain.
A 45‑year‑old man has unilateral headache and notices that one side of his face does not sweat. He has mild ptosis.
Most likely diagnosis?
Answer: Horner syndrome from carotid dissection
Why: Anhidrosis + ptosis + headache → sympathetic chain disruption.
A 29‑year‑old woman has severe headache that improves after vomiting. She has photophobia and phonophobia. Neuro exam is normal.
Most likely diagnosis?
Answer: Migraine
Why: Vomiting can relieve intracranial pressure transiently in migraine.
A 70‑year‑old woman has new headaches and jaw fatigue when chewing. ESR is 18.
Next best step?
Answer: Start steroids immediately
Why: ESR can be normal in up to 20% of GCA cases. Jaw claudication is highly specific.
A 42‑year‑old man has severe headache, fever, and diplopia. He has a recent history of otitis media. Exam shows lateral gaze palsy.
Most likely diagnosis?
Answer: Petrous apicitis (Gradenigo syndrome)
Why: Otitis media + CN VI palsy + headache = petrous apex infection.
If you want to keep going, I can craft:
Just tell me how far you want to push this.
Silverio, you’re going to love this one — Set #7 is where the examiners stop playing fair. These are the curveballs designed to test whether you can see through misdirection, recognize rare-but-testable patterns, and apply the headache algorithm under pressure.
Let’s dive in.
A 36‑year‑old woman has recurrent unilateral headaches with nausea and photophobia. Today’s episode is different: she has left‑arm weakness that persists after the headache resolves. CT head is normal.
Most likely diagnosis?
Answer: Hemiplegic migraine
Why: Persistent focal deficits + migraine features. Normal CT rules out hemorrhage.
A 52‑year‑old man has unilateral headache, ear pain, and vesicles in the external auditory canal. He also has facial paralysis.
Most likely diagnosis?
Answer: Ramsay Hunt syndrome (herpes zoster oticus)
Why: Ear vesicles + facial palsy + pain.
A 44‑year‑old woman has severe unilateral headache, nausea, and blurred vision. Her intraocular pressure is normal. Pain worsens when she looks laterally.
Most likely diagnosis?
Answer: Tolosa–Hunt syndrome
Why: Painful ophthalmoplegia with normal IOP.
A 29‑year‑old man has headache, fever, and new personality changes. CT head is normal. LP shows lymphocytic pleocytosis.
Most likely diagnosis?
Answer: HSV encephalitis
Why: Behavioral changes + lymphocytic CSF + normal CT.
A 41‑year‑old woman has morning headaches, amenorrhea, and cold intolerance. Visual fields show bitemporal hemianopsia.
Most likely diagnosis?
Answer: Pituitary macroadenoma
Why: Mass effect + endocrine dysfunction.
A 55‑year‑old man has paroxysmal stabbing pain in the occipital region triggered by touching the scalp.
Most likely diagnosis?
Answer: Occipital neuralgia
Why: Triggerable occipital pain.
A 60‑year‑old man with diabetes has headache and horizontal diplopia. His eye is deviated medially at rest. Pupils are normal.
Most likely diagnosis?
Answer: CN VI palsy from microvascular ischemia
Why: Lateral rectus palsy + diabetes + pupil sparing.
A 48‑year‑old man with sinusitis develops headache, fever, and confusion. CT shows frontal lobe hypodensity.
Most likely diagnosis?
Answer: Frontal lobe abscess
Why: Sinusitis → contiguous spread → frontal abscess.
A 32‑year‑old woman has a headache that improves when standing and worsens when lying down. No recent procedures.
Most likely diagnosis?
Answer: Idiopathic intracranial hypertension
Why: IIH headaches worsen when lying down; improve upright.
A 68‑year‑old woman has new headaches and scalp tenderness. ESR is 22.
Next best step?
Answer: Start steroids immediately
Why: ESR can be normal in GCA. Scalp tenderness is highly specific.
If you want to keep pushing, I can create:
Tell me how intense you want the next round to be.
Silverio, you’re asking for Set #8, the impossible‑mode, zebra‑level headache cases — the ones designed to break pattern‑recognition, punish assumptions, and force you to integrate neurology, infectious disease, rheumatology, oncology, and ophthalmology all at once.
These are the kinds of cases that show up on the hardest shelf exams and board vignettes.
Let’s get into it.
A 69‑year‑old woman has new headaches and says “my hair hurts when I touch it.” ESR and CRP are normal. Temporal artery ultrasound shows a “halo sign.”
Most likely diagnosis?
Answer: Giant cell arteritis
Why: ESR/CRP can be normal. The halo sign is highly specific.
A 32‑year‑old woman has acute bilateral vision loss and severe headache. Fundoscopy is normal. MRI shows symmetric lesions in the occipital lobes.
Most likely diagnosis?
Answer: Posterior reversible encephalopathy syndrome (PRES)
Why: Occipital edema → cortical blindness with normal fundus.
A 40‑year‑old man has severe headache, fever, diplopia, and difficulty opening his mouth. He recently had a dental infection.
Most likely diagnosis?
Answer: Masticator space infection with cavernous sinus involvement
Why: Dental source + trismus + cranial nerve involvement.
A 29‑year‑old woman has chronic headaches and pulsatile tinnitus. MRI/MRV are normal. LP opening pressure is 28 cm H₂O.
Most likely diagnosis?
Answer: Idiopathic intracranial hypertension
Why: Pulsatile tinnitus is a classic but often overlooked clue.
A 44‑year‑old man has episodic headaches preceded by a burning‑rubber smell. He then becomes confused for several minutes.
Most likely diagnosis?
Answer: Temporal lobe epilepsy
Why: Olfactory aura + postictal confusion.
A 37‑year‑old man has headache, fever, and a maculopapular rash on the palms and soles. He recently returned from a camping trip.
Most likely diagnosis?
Answer: Rocky Mountain spotted fever
Why: RMSF can present with severe headache before full rash.
A 55‑year‑old woman has severe retro‑orbital headache and ophthalmoplegia. MRI shows inflammation of the cavernous sinus and superior orbital fissure.
Most likely diagnosis?
Answer: Tolosa–Hunt syndrome
Why: Painful ophthalmoplegia + granulomatous inflammation.
A 48‑year‑old man has occipital headache, ataxia, and burning dysesthesias in his hands. MRI shows a dorsal column lesion.
Most likely diagnosis?
Answer: Neurosyphilis (tabes dorsalis)
Why: Dorsal column degeneration + headache + sensory ataxia.
A 34‑year‑old woman has unilateral headache, ear fullness, and jaw clicking. Pain worsens with chewing.
Most likely diagnosis?
Answer: Temporomandibular joint disorder
Why: Ear fullness + jaw clicking + chewing‑related pain.
A 52‑year‑old man has headache, fever, and vertical diplopia. He recently had sinusitis. Exam shows impaired downward gaze.
Most likely diagnosis?
Answer: Trochlear nerve palsy from sphenoid sinusitis
Why: CN IV runs close to the sphenoid sinus → infection can cause isolated palsy.
If you want to go even deeper, I can create:
Just tell me how far you want to push this.
Silverio, welcome to Set #9 — Nightmare Mode, the tier designed to trick neurologists, intimidate residents, and make board exam writers smile. These cases weaponize subtlety, mimicry, and rare-but-testable pathologies. If you can reason through these, you’re operating at a genuinely elite level.
Let’s begin.
A 41‑year‑old woman reports headaches and transient bilateral vision loss lasting 5–10 seconds when she stands up. Fundoscopy is normal. MRI brain is normal. BP is 98/60 sitting, 78/50 standing.
Most likely diagnosis?
Answer: Orthostatic hypotension causing transient retinal hypoperfusion
Why: Vision loss on standing + normal fundus + hypotension → not IIH, not migraine aura.
A 55‑year‑old man has unilateral headache and notes that one pupil does not dilate in the dark. He also has mild ptosis. No trauma.
Most likely diagnosis?
Answer: Internal carotid artery dissection causing partial Horner syndrome
Why: Anisocoria worse in the dark = sympathetic defect.
A 38‑year‑old woman has headaches and vertical diplopia only when reading. Neuro exam shows subtle difficulty with downward gaze.
Most likely diagnosis?
Answer: Trochlear nerve palsy
Why: CN IV palsy → vertical diplopia worse with down gaze (reading, stairs).
A 44‑year‑old man has headache, fever, and severe neck pain that worsens with rotation. No photophobia. No meningismus.
Most likely diagnosis?
Answer: Retropharyngeal abscess
Why: Neck rotation pain + fever + headache → deep neck space infection.
A 35‑year‑old woman has unilateral headache and upper tooth pain. Sinus CT is normal. Pain worsens with cold air.
Most likely diagnosis?
Answer: Maxillary division trigeminal neuralgia
Why: V2 distribution pain often misdiagnosed as dental or sinus disease.
A 29‑year‑old man has occipital headaches and a clicking sensation when rotating his neck. Neuro exam is normal. MRI shows atlantoaxial instability.
Most likely diagnosis?
Answer: Cervicogenic headache from C1–C2 instability
Why: Occipital pain + mechanical neck symptoms.
A 50‑year‑old man has headaches and jaw pain when chewing tough foods but not soft foods. No scalp tenderness. ESR is normal.
Most likely diagnosis?
Answer: Temporomandibular joint dysfunction
Why: TMJ pain is load‑dependent; GCA jaw claudication is ischemic and occurs even with soft foods.
A 47‑year‑old woman has headache and a red eye. She denies pain. Vision is normal. IOP is normal. She recently had a viral illness.
Most likely diagnosis?
Answer: Episcleritis
Why: Red eye without pain or vision loss → benign, but can mimic dangerous causes.
A 58‑year‑old woman with breast cancer presents with headache and difficulty looking upward. She has nausea and vomiting. Fundoscopy shows papilledema.
Most likely diagnosis?
Answer: Parinaud syndrome from dorsal midbrain metastasis
Why: Upward gaze palsy + cancer history + increased ICP.
A 62‑year‑old man has headaches that worsen when lying on his left side and improve when upright. MRI shows a small left cerebellopontine angle mass.
Most likely diagnosis?
Answer: Positional headache from vestibular schwannoma
Why: Tumor shifts with gravity → positional symptoms.
If you want to keep going, I can escalate to:
Just tell me how far you want to push this.
Here we go, Silverio—Set #10: Boss Level. These are built to break pattern recognition and force you to slow down, anchor in physiology, and really interrogate each clue.
A 63‑year‑old man on warfarin for atrial fibrillation develops a new, severe unilateral headache with nausea and photophobia. He has had “migraines” in the past, but this one is more intense and started abruptly. INR is 3.4. Neuro exam is normal.
Most likely diagnosis?
Answer: Subdural or intracranial hemorrhage until proven otherwise
Why: New, severe headache + anticoagulation + change from prior pattern → treat as bleed, not migraine.
A 35‑year‑old woman reports recurrent episodes of visual zigzag lines and scintillations lasting 20–30 minutes, followed by mild fatigue but no headache. Neuro exam is normal.
Most likely diagnosis?
Answer: Migraine aura without headache (acephalgic migraine)
Why: Classic aura phenomena without subsequent pain.
A 28‑year‑old man develops sudden severe occipital headache during heavy weightlifting. Neuro exam is normal. CT head is normal.
Next best step?
Answer: MRI/MRA of brain and neck
Why: Exertional thunderclap → consider aneurysm, RCVS, or dissection despite normal CT.
A 46‑year‑old woman has unilateral headache, red eye, and miosis. The eye is not painful. She has mild ptosis. IOP is normal.
Most likely diagnosis?
Answer: Horner syndrome from carotid pathology (e.g., dissection or mass)
Why: Redness can be conjunctival; key is miosis + ptosis + headache.
A 39‑year‑old woman has chronic headaches and unilateral pulsatile tinnitus in the right ear. MRI brain is normal. MRV shows a dural arteriovenous fistula.
Most likely diagnosis?
Answer: Dural AV fistula causing pulsatile tinnitus and headache
Why: Unilateral pulsatile tinnitus is a vascular red flag, not just IIH.
A 30‑year‑old man has subacute headache and neck stiffness but no fever. He recently had a chiropractic neck manipulation. Neuro exam shows mild left arm weakness.
Most likely diagnosis?
Answer: Vertebral artery dissection
Why: Neck manipulation + neck pain/stiffness + focal deficit.
A 42‑year‑old man has chronic frontal headaches and progressive anosmia. MRI shows a midline mass at the base of the frontal lobes.
Most likely diagnosis?
Answer: Olfactory groove meningioma
Why: Anosmia + frontal headaches + midline anterior cranial fossa mass.
A 33‑year‑old obese woman has headaches and transient visual blurring when bending over or tying her shoes. Fundoscopy shows papilledema. MRI is normal.
Next best step?
Answer: Lumbar puncture to measure opening pressure
Why: Positional visual symptoms + papilledema → confirm IIH.
A 52‑year‑old man has occipital headaches and gait instability. He describes his walking as “bouncy.” MRI shows tonsillar herniation through the foramen magnum.
Most likely diagnosis?
Answer: Chiari I malformation
Why: Occipital headache + imbalance + tonsillar descent.
A 47‑year‑old woman has brief, explosive headaches triggered by coughing, laughing, or straining. Neuro exam is normal.
Next best step?
Answer: MRI brain with focus on posterior fossa
Why: Primary cough headache is a diagnosis of exclusion—must rule out Chiari, mass, or aneurysm.
If you want, next we can:
Think of this as a single flow you can run in your head every time.
If any red flag is present, treat as secondary headache until proven otherwise.
If ANY red flag → go to Step 3 (secondary workup).
If NO red flags → skip to Step 4 (primary vs special patterns).
Thunderclap headache (± exertion/sex/cough):
Fever + headache ± neck stiffness / confusion:
Focal neurologic deficits, seizures, progressive symptoms, cancer/HIV:
Papilledema ± visual symptoms:
Hypertensive emergency (very high BP + neuro signs):
Red eye + severe pain + vision loss:
New headache >50 years ± jaw claudication, scalp tenderness, visual symptoms:
Postpartum, hypercoagulable, headache ± seizures, focal deficits, papilledema:
Sinusitis/otitis + headache + cranial nerve deficits:
Neck trauma or manipulation + neck pain/headache ± Horner/focal deficits:
Cancer/HIV + new headache with normal CT:
If a secondary cause is found → treat that condition.
If no secondary cause and red flags are resolved/low → proceed to Step 4.
Migraine (± aura):
Tension-type:
Cluster / trigeminal autonomic cephalalgias:
Medication‑overuse headache:
Primary cough/exertional/sexual headache:
Acephalgic migraine:
These sit between primary and secondary in your mental map and showed up repeatedly in the cases:
Idiopathic intracranial hypertension (IIH):
Spontaneous intracranial hypotension (CSF leak):
Carotid/vertebral dissection:
Pituitary apoplexy / macroadenoma:
PRES (posterior reversible encephalopathy syndrome):
Cerebral venous sinus thrombosis:
Giant cell arteritis / PMR overlap:
Infectious/autoimmune zebras (HSV encephalitis, neurosyphilis, RMSF, etc.):
When you see a headache, run this in order:
If you’d like, next step could be:
++++++++++++
Absolutely, Silverio — let’s turn the entire master headache‑diagnosis algorithm into a clean, visual, flowchart‑style layout you can scan instantly.
No images needed — just a crisp, structured, visual logic map.
↓
IF ANY RED FLAG → Go to Step 3 (Secondary Workup)
IF NO RED FLAGS → Go to Step 4 (Primary Headache Classification)
→ CT head (non‑contrast)
→ If negative + high suspicion → LP
→ MRI brain ± MRA/CTA
→ MRI + MRV
→ Then LP with opening pressure
→ CT/MRI
→ IOP measurement (rule out acute glaucoma)
→ ESR/CRP
→ Start steroids
→ Temporal artery biopsy/ultrasound
→ MRI + MRV (venous sinus thrombosis)
→ CT/MRI (cavernous sinus thrombosis, petrous apicitis)
→ CTA/MRA neck (carotid/vertebral dissection)
→ MRI with contrast
If secondary cause found → treat accordingly
If negative → proceed to Step 4
If:
→ Primary headache diagnosis confirmed
If:
→ Re‑evaluate for secondary causes
If you want, I can also turn this into: