Voiceover: 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.
Margaret Fitzgerald: A 25-year-old woman presents for follow-up with a 12-year history of intermittent headache reported as unilateral throbbing pain with nausea, photophobia, phonophobia, that usually lasts about 12 to 24 hours. At the onset of her headache, she takes oral high-dose ibuprofen with sumatriptan, reporting, "My headache is usually gone within an hour or so." She reports no particular pattern to the headache trigger and denies headache prodrome. Family history is positive for mother and sister with similar headache. She's currently headache-free and her neuro exam is within normal limits. Today she asks if she needs "any test to find out what causes my headache."
The NP considers the following:
A. Order a head MRI due to duration of headache.
B. Order a head CT with contrast due to frequency of headache.
C. Discuss the utility of carotid Doppler ultrasonography in confirming the diagnosis of migraine.
D. Advise the patient that neuroimaging is not routinely indicated in this clinical scenario.
And the correct answer is D. Advise the patient that neuroimaging is not routinely indicated in this clinical scenario.
Where should you start with this question? First, determine what kind of a question this is. Given that we've been provided with a diagnosis, an effective treatment plan has been developed and used. This question focuses on whether specific diagnostics are indicated. Therefore, it's an evaluation question looking at whether a plan of care needs to be altered or not.
How about a little bit of background information first? The two most common primary headache types are migraine and tension-type headache. Please recall primary headaches are those not associated with other diseases. This question focuses on a younger woman with migraine. Of course, you might ask, how do we know the diagnosis is correct? We're really provided with ample evidence that migraine is her diagnosis, because of the pattern of the headache, her signs and symptoms with her headache, strong family history, etc. And one of the most reassuring findings in a report of headache is just what we're hearing here, the same headache over and over and over again. She also reports something that is additionally reassuring, that the same treatment helps her headache every single time. She takes a decent dose of ibuprofen, an NSAID, that helps with the pain. And then she also takes a migraine-specific drug, a triptan. And what the triptan does is it provides coverage in treatment of the non-pain symptomatology with migraine, like the photophobia and phonophobia.
In other words, today her headache has no new features and no worrisome findings. And I'm going to just throw one more thing in there. Doing the math here, she likely started getting migraine around the time of her first menstrual period, around the time of menarche, which is very common in young women. Keep in mind, with migraine, or for that matter any other primary headache, between headaches the neuro exam is perfectly normal. During headache, the only acceptable neuro changes are photophobia and/or phonophobia.
Of course, you can't talk about headaches without mentioning secondary headache. Secondary headaches are those associated with some other kind of condition, like increased intracranial pressure, intracranial bleed, and rarely brain tumor. I know a lot of times, particularly when you're new to practice, that's one thing that people will say is, "Oh, I've got a patient with recurrent headache. I'm afraid I'm going to miss a brain tumor." Brain tumors don't usually present with headache. And less than 20% of people presenting with brain tumor will report new onset or new type of headache. More likely it's an isolated seizure or some other abnormality in the neuro exam.
So back to migraine. It's a clinical diagnosis based primarily on the patient's history, symptom pattern, and risk factors, rather than one particular lab test, imaging study, or biomarker. And that's the presentation that we've had in this patient scenario.
With this information in mind, let's take another look at the question. A 25-year-old presents for follow-up on a 12-year history of intermittent headache reported as unilateral throbbing pain with nausea, photophobia, phonophobia, and usually lasting 12 to 24 hours. At headache onset, she takes an oral high-dose ibuprofen with sumatriptan, reporting, "My headache is usually gone within an hour or so." She reports no particular pattern to headache trigger and denies headache prodrome. Family history is positive for sister and mother with similar headaches. Today she is currently headache-free and neuro exam is within normal limits. She also asks if she needs "any test to find out what causes my headaches."
The NP considers the following:
A. Order a head MRI due to the duration of headache. What does the American Headache Society recommend on neuroimaging and migraine? This is what they say: there's no necessity to doing neuroimaging in patients with headache consistent with migraine who have a normal neuro exam, no atypical features or red flags. So remember, we've got backup from the American Headache Society and the American Academy of Neurology that she does not need imaging. Also, the other thing is, primary headache is one of the most common chronic pain conditions you will see in primary and urgent care.
B. Order a head CT with contrast due to frequency of headaches. Again, this is incorrect. Neuroimaging is not warranted. When neuroimaging is warranted in suspected secondary headache, CT is preferred for acute emergent conditions, like the possibility of hemorrhage or trauma, due to its speed and availability. MRI is generally preferred for evaluating non-emergent secondary causes because of its greater sensitivity for intracranial pathology. You might also take comfort in the fact that there has been a number of studies done that looked at individuals with longstanding primary headache, compared them to age, birth, sex assignment, etc. match controls who literally never get headaches, and neuroimaging was done on both these groups. So, one more time: the group with primary headache, the group who never gets a headache, there are virtually no differences between these two groups of people in abnormalities that were found on neuroimaging.
C. Discuss the utility of carotid Doppler ultrasonography in confirming the diagnosis of migraine. Now, this is, to me, the example of the so-far-out-in-left-field option, because carotid Doppler plays no role, zero role, in diagnosing or treating migraine. It would rarely be indicated in any headache type unless there was concern about significant vascular pathology.
Key takeaway: knowing when not to order a diagnostic study is as important in clinical practice as knowing when to obtain these studies.
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