FNP Headache and Migraine Practice Questions

Accepting gifts of significant monetary value from patients crosses professional boundaries and can create a sense of obligation or alter the therapeutic dynamic. The FNP should politely decline the gift while acknowledging the patient's gratitude. Option A violates ethical guidelines regarding financial boundaries and dual relationships, regardless of documentation. Option C, while seemingly altruistic, still involves accepting a high-value gift from a patient, which remains ethically problematic. Option D also violates the boundary by accepting the high-value item, regardless of who ultimately uses it within the clinic. Option B maintains professional boundaries while preserving the therapeutic relationship.

Tension-type headaches present with bilateral, non-pulsating, band-like pain that is not aggravated by routine physical activity. They may feature mild photophobia or phonophobia, but never both, and they lack nausea. Migraines are unilateral, pulsating, and are worsened by routine activity. Medication overuse requires a specific history of frequent analgesic use over months. Cervicogenic headaches typically involve unilateral neck pain that is triggered by specific neck movements or sustained postures.

The sudden onset of severe hypertension in a young, healthy female without risk factors strongly points toward a secondary cause. The presence of a periumbilical bruit is a highly specific physical exam finding for renovascular hypertension, which in this demographic is most commonly caused by fibromuscular arterial dysplasia. Primary adrenal hyperaldosteronism typically presents with hypokalemia and muscle weakness rather than a localized abdominal bruit. Adrenal medullary pheochromocytoma would cause paroxysmal blood pressure spikes accompanied by a classic triad of severe headaches, palpitations, and diaphoresis. Aortic arch coarctation would present with diminished or delayed femoral pulses and a significant blood pressure discrepancy between the upper and lower extremities, not an isolated abdominal bruit.

To diagnose polymyalgia rheumatica, clinicians look for evidence of systemic inflammation without actual muscle tissue destruction. Therefore, an elevated C-reactive protein or erythrocyte sedimentation rate paired with normal muscle enzymes like creatine kinase is the expected laboratory pattern. Elevated creatine kinase with a normal ESR would point toward a myopathy such as polymyositis or statin-induced myotoxicity, not polymyalgia rheumatica. A positive rheumatoid factor with an elevated CRP would suggest rheumatoid arthritis, which is a key differential but less likely given the classic proximal girdle presentation without small joint involvement. A positive antinuclear antibody with a normal CRP might suggest systemic lupus erythematosus, but lupus typically presents in younger females and lacks the isolated severe proximal stiffness seen in this older male patient.

The development of a new temporal headache and jaw claudication during a polymyalgia rheumatica taper strongly suggests giant cell arteritis. This is a medical emergency requiring immediate treatment with high-dose corticosteroids, typically 40 to 60 mg of prednisone daily, to prevent irreversible vision loss. Increasing the dose to 10 mg is appropriate for a simple disease flare but is completely inadequate for giant cell arteritis. While imaging or a biopsy will eventually be needed to confirm the diagnosis, you should never delay the initiation of high-dose steroids to wait for an MRI or ultrasound.

The diagnostic criteria for tension-type headaches allow for either mild photophobia or mild phonophobia, but explicitly state that a patient cannot have both. If a patient experiences both photophobia and phonophobia, the diagnosis shifts toward migraine. Option B is incorrect because tension headaches frequently involve pericranial muscle tenderness and radiation to the posterior neck. Option C is incorrect as both tension headaches and migraines can easily last for four hours. Option D describes a postdrome phase of fatigue, which is common in migraines but can also be reported by patients recovering from a prolonged tension-type headache.

Melatonin is generally safe, but higher doses frequently cause vivid dreams or nightmares due to alterations in REM sleep architecture. Option A is incorrect because sleepwalking is not a typical side effect of melatonin, though it happens with prescription Z-drugs. Option B is wrong as morning headaches can occasionally occur but do not indicate a dangerous allergic reaction. Option D is incorrect because sleep paralysis is not a recognized common side effect of melatonin therapy and would warrant further neurological evaluation.

The patient is experiencing brief, paroxysmal, stabbing pain triggered by the movement of speaking, which strongly points to classic trigeminal neuralgia affecting the maxillary branch. The normal C-reactive protein level helps rule out systemic inflammatory conditions. Giant cell arteritis typically presents with a continuous temporal headache, potential visual changes, and elevated inflammatory markers like C-reactive protein. Temporomandibular joint disorder involves a dull, aching pain localized to the joint space that worsens with prolonged chewing, rather than stabbing superficial pain. Acute maxillary sinusitis causes a continuous, dull, pressure-like pain over the cheek that worsens when bending forward, often accompanied by purulent nasal discharge, which is absent here.

The patient's presentation strongly suggests a hypoglycemic mimic of a TIA. While sudden unilateral weakness and aphasia are classic for a TIA, the documented blood glucose of 42 mg/dL at onset points to neuroglycopenia, which can cause reversible focal deficits. A transient ischemic attack is less likely given the profound hypoglycemia that perfectly aligns with symptom timing. A focal aware seizure typically presents with positive motor symptoms like jerking rather than isolated weakness. A hemiplegic migraine aura usually features a gradual progression of symptoms and is often followed by a headache, making it an unlikely cause for this sudden, brief presentation in an older adult.

This patient's presentation is highly suspicious for giant cell arteritis, a medical emergency that can lead to irreversible vision loss. The standard of care is to immediately initiate high-dose corticosteroids and initiate an urgent rheumatology referral to coordinate a temporal artery biopsy and manage long-term care. Option B is incorrect because treatment must never be delayed while awaiting a biopsy. Option C is incorrect because NSAIDs are insufficient to prevent ischemic complications. Option D is incorrect because a CT scan does not diagnose this condition and delays necessary treatment.