Headache: MCCQE1 Preparation Guide

Introduction

Headache is one of the most common reasons for neurological consultation in Canada. For the MCCQE1, the candidate must demonstrate the ability to differentiate between benign primary headaches and life-threatening secondary causes. The Medical Council of Canada (MCC) expects a structured approach aligned with the CanMEDS framework, specifically the Medical Expert role, emphasizing history taking, physical examination, and appropriate resource stewardship (Choosing Wisely Canada).

SNOOP10 Mnemonic for Secondary Headaches

• Systemic symptoms (fever, weight loss) or Secondary risk factors (HIV, cancer)
• Neurologic symptoms or abnormal signs (confusion, impaired alertness, focal signs)
• Onset sudden (Thunderclap headache - think Subarachnoid Hemorrhage)
• Older patient (New onset >50 years - think Giant Cell Arteritis or Mass lesion)
• Pattern change (progressive, worst headache of life) or Papilledema
• Precipitated by Valsalva (coughing, sneezing)
• Postural aggravation
• Pregnancy or Puerperium
• Painful eye with autonomic features
• Post-traumatic onset
• Pathology of the immune system (HIV, immunosuppression)
• Painkiller overuse (Medication Overuse Headache)

Classification of Headaches

Headaches are broadly classified into two categories based on the International Classification of Headache Disorders (ICHD-3).

Clinical Evaluation

For MCCQE1 preparation, focus on a focused history and physical exam to rule out red flags.

Primary Headaches: Comparative Overview

This section is high-yield for MCCQE1. You must be able to distinguish these based on clinical presentation.

Important Secondary Headaches

1. Giant Cell Arteritis (Temporal Arteritis)

• Context: Medical Emergency. Can cause permanent blindness.
• Patient: Age >50 (usually >70).
• Symptoms: New headache, scalp tenderness (hair brushing), jaw claudication (highest predictive value), visual disturbances (amaurosis fugax).
• Labs: Elevated ESR (>50 usually) and CRP.
• Gold Standard Dx: Temporal Artery Biopsy.
• Management: Start High-Dose Corticosteroids (Prednisone) IMMEDIATELY upon suspicion. Do not wait for biopsy results.

2. Subarachnoid Hemorrhage (SAH)

• Presentation: “Thunderclap” headache (reaches peak intensity instantly).
• Workup:
  1. CT Head (Non-contrast): >95% sensitivity in first 6-12 hours.
  2. Lumbar Puncture: If CT is negative and clinical suspicion remains high. Look for Xanthochromia (yellow supernatant from bilirubin breakdown, present >12 hours post-bleed).

3. Medication Overuse Headache (MOH)

• Definition: Headache occurring ≥15 days/month in a patient with pre-existing headache disorder, due to regular overuse of acute medication for >3 months.
• Culprits: Opioids, Butalbital (Fiorinal), Triptans (≥10 days/month), Simple analgesics (≥15 days/month).
• Management: Patient education, withdrawal of offending agent (abrupt or tapered), initiation of prophylaxis.

Canadian Guidelines & Choosing Wisely

Understanding resource stewardship is vital for the MCCQE1.

Toward Optimized Practice (TOP) Guidelines (Alberta)

• Encourage the use of headache diaries.
• Stratify migraine treatment:
  • Mild-Moderate: NSAIDs (Ibuprofen, Naproxen), Acetaminophen, ASA.
  • Moderate-Severe: Triptans (Almotriptan, Eletriptan, Rizatriptan, Sumatriptan, Zolmitriptan).
  • Emergency: Antiemetics (Metoclopramide) + Dihydroergotamine (DHE) or Ketorolac.

Key Points to Remember for MCCQE1

• Rule out GCA in any patient >50 with a new headache. Treat with steroids immediately if suspected.
• Thunderclap headache requires urgent non-contrast CT. If negative, perform LP.
• Migraine patients want to lie still in a dark room; Cluster headache patients pace around.
• Neuroimaging is NOT indicated for patients with a clear history of primary headache and a normal neurological exam.
• Pregnancy: Acetaminophen is the safest analgesic. Avoid NSAIDs in the third trimester. Triptans are generally avoided unless benefit outweighs risk (consult guidelines).
• Post-LP Headache: Positional headache (worse standing, better lying down). Treatment is fluids, caffeine, and blood patch if persistent.

Sample Question

Explanation

The correct answer is:

• C. Prescribe oral sumatriptan

Explanation: The patient presents with symptoms classic for Migraine without aura (unilateral, throbbing, disabling, nausea, photophobia).

• Option C is correct: For moderate to severe migraine attacks that do not respond to simple analgesics (like acetaminophen), a Triptan (5-HT1B/1D agonist) such as Sumatriptan is the first-line specific acute therapy according to Canadian guidelines.
• Option A is incorrect: Opioids (codeine) are not recommended for routine migraine treatment due to the risk of medication overuse headache and addiction. Choosing Wisely Canada specifically advises against this.
• Option B is incorrect: In a young patient with a typical history of primary headache and a normal neurological exam, neuroimaging is not indicated. It exposes the patient to unnecessary radiation (if CT) and utilizes resources inefficiently.
• Option D is incorrect: Prophylactic therapy (e.g., propranolol) is generally considered when headaches are frequent (>4 days/month) or severely disabling. This patient has 3 attacks/month; optimizing acute treatment is the first step before committing to daily prophylaxis.
• Option E is incorrect: Steroids are not a standard first-line abortive therapy for typical migraine. They are sometimes used for status migrainosus (migraine lasting >72 hours).

References

1. Medical Council of Canada. (2023). MCCQE Part I Clinical Decision-Making and Multiple-Choice Question Objectives.
2. Choosing Wisely Canada. (2023). Neurology and Family Medicine Recommendations regarding Headache. Available at: https://choosingwiselycanada.org/ 
3. Toward Optimized Practice (TOP). (2016). Primary Care Management of Headache in Adults. Alberta Medical Association.
4. International Headache Society. (2018). The International Classification of Headache Disorders, 3rd edition (ICHD-3).
5. Becker, W. J., et al. (2015). Guideline for primary care management of headache in adults. Canadian Family Physician, 61(8), 670-679.