Q-Bank Breakdown: Migraine vs tension vs cluster headache — Why Every Answer Choice Matters

Headache questions are the classic “I know this… wait, do I?” trap on UWorld/NBME. The stem feels familiar, the answer choices all sound plausible, and suddenly you’re second-guessing whether photophobia belongs to everyone. The key to consistently nailing these is not memorizing a list—it’s learning how each feature pushes probability toward one diagnosis and away from the others.

Tag: Neurology > Seizures, Headache & Sleep

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The Q-bank vignette

A 29-year-old woman presents with recurrent headaches for the past year. Episodes occur 1–2 times per month, last 6–18 hours, and are unilateral and throbbing. She prefers to lie in a dark room and reports nausea and photophobia during attacks. She sometimes notices “shimmering zig-zag lines” in her vision before the headache starts. Neurologic exam is normal.

What is the most likely diagnosis?

A. Cluster headache
B. Migraine headache
C. Subarachnoid hemorrhage
D. Tension-type headache
E. Trigeminal neuralgia

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Correct answer: B. Migraine headache

This stem is migraine until proven otherwise:

Why this is migraine

Core pattern

• Recurrent attacks lasting 4–72 hours
• Unilateral, pulsating/throbbing
• Moderate–severe pain
• Worse with routine activity
• Associated nausea/vomiting and/or photophobia + phonophobia

The giveaway here: visual aura (“shimmering zig-zag lines”) → migraine with aura.

Migraine with aura (high-yield)

• Aura symptoms are usually visual (scintillations, fortification spectra), but can be sensory or speech-related.
• Timing: aura often precedes headache and evolves over minutes; typical aura lasts 5–60 minutes.
• Pathophys concept: cortical spreading depression (Step 1 favorite).

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How you treat migraine (USMLE style)

Acute (abortive) therapy

• NSAIDs (ibuprofen, naproxen)
• Triptans (e.g., sumatriptan) = 5-HT$_{1B/1D}$ agonist → cranial vasoconstriction + ↓ trigeminal neurotransmission
  • Avoid in ischemic heart disease, uncontrolled HTN, hemiplegic/basilar migraine
• Antiemetics (metoclopramide, prochlorperazine) often paired in ED settings

Preventive therapy (think: frequent or disabling)

Start if ≥4 headache days/month, prolonged attacks, or significant impairment.

Special warning (Step 2 counseling)

• Migraine with aura + estrogen-containing OCPs → increased ischemic stroke risk. Consider progestin-only methods if contraception needed.

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Now kill the distractors (why each answer choice matters)

A. Cluster headache

Why it’s tempting: unilateral headaches are common to both migraine and cluster.
Why it’s wrong here: the timeline and associated features don’t match.

Cluster pattern (memorize the vibe):

• Severe, unilateral orbital/supraorbital/temporal pain
• Duration: 15–180 minutes
• Frequency: up to 8/day
• Occurs in clusters (weeks–months), then remission
• Ipsilateral autonomic symptoms: lacrimation, conjunctival injection, rhinorrhea, nasal congestion, ptosis, miosis
• Patient is often restless/agitated (paces), not lying still in a dark room

Treatment (high-yield):

• Abort: 100% oxygen, subQ sumatriptan
• Prevent: verapamil (first-line)

Quick discrimination tip:

• Migraine patients want dark + still.
• Cluster patients are up + pacing, with a “wet eye/runny nose” on the same side.

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C. Subarachnoid hemorrhage (SAH)

Why it’s tempting: severe headache disorders are a common exam pivot.
Why it’s wrong here: this stem is recurrent, not sudden catastrophic onset.

SAH pattern:

• “Thunderclap” = maximal intensity within 1 minute
• “Worst headache of my life”
• Often with neck stiffness, meningismus, altered mental status, or focal deficits

Workup (Step 2 algorithm):

1. Non-contrast head CT
2. If CT negative but suspicion high → LP (xanthochromia, elevated RBCs)

Key contrast: migraine is episodic and stereotyped; SAH is abrupt and emergent.

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D. Tension-type headache

Why it’s tempting: very common, benign, “stress headache.”
Why it’s wrong here: this patient has nausea + photophobia and a throbbing unilateral headache with aura—classic migraine features.

Tension-type pattern:

• Bilateral, “band-like,” pressing/tightening (non-pulsatile)
• Mild–moderate, not worsened by activity
• No nausea/vomiting
• May have either photophobia or phonophobia, but usually not both

Treatment:

• Acute: NSAIDs, acetaminophen
• Prevent (chronic tension): amitriptyline is classic

Exam pearl: if you see nausea + photophobia with pulsatile pain, your default should be migraine, not tension.

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E. Trigeminal neuralgia

Why it’s tempting: facial pain is neurologic and episodic.
Why it’s wrong here: trigeminal neuralgia is not a prolonged headache syndrome; it’s brief, shock-like facial pain.

Trigeminal neuralgia pattern:

• Sudden, severe, electric shock-like pain
• Lasts seconds, occurs in paroxysms
• Triggered by light touch, chewing, brushing teeth
• Distribution: CN V2/V3 > V1

Treatment:

• First-line: carbamazepine (also oxcarbazepine)
• Consider secondary causes (especially in younger patients): multiple sclerosis

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The “one table” you actually need for Step exams

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High-yield “trap doors” exam writers love

• Sinus headache is often migraine. If there’s “pressure” + “congestion” but also photophobia or nausea, think migraine.
• Papilledema + worse when lying down → consider increased ICP (mass, idiopathic intracranial hypertension), not primary headache.
• New headache after age 50 + jaw claudication/vision symptoms → giant cell arteritis (ESR/CRP, steroids now).
• Unilateral headache + ptosis + miosis + anhidrosis (Horner) can occur with cluster, but if accompanied by neck pain/trauma think carotid dissection.

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Take-home: how to pick the right answer fast

1. Duration is your first filter (minutes vs hours vs sudden thunderclap).
2. Look for autonomic symptoms + restlessness → cluster.
3. Look for nausea/photophobia + throbbing ± aura → migraine.
4. Look for bilateral band-like, no nausea → tension.