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Cluster headache — SCE Neurology MCQ

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HardHeadacheCluster headacheSCE Neurology

A 41-year-old has a 6-week orthostatic headache, diffuse pachymeningeal enhancement and a spinal longitudinal epidural collection, without preceding dural puncture or trauma. A high-volume non-targeted epidural blood patch produced near-complete relief, but the headache recurred 10 days later. Which planned next step best follows the multidisciplinary consensus pathway?

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Correct answer: D — Offer a second high-volume non-targeted epidural blood patch after 2–4 weeks

This is spontaneous intracranial hypotension, supported by the orthostatic phenotype, pachymeningeal enhancement and spinal longitudinal epidural collection. After no response or only a transient response to a first non-targeted epidural blood patch, the consensus guideline allows a second high-volume non-targeted patch before proceeding to myelography, with a recommended interval of 2–4 weeks after the first patch or symptom recurrence. Myelography is then used to localise a leak for targeted treatment when non-targeted patching has failed or provided only temporary benefit. Lumbar puncture is not required solely to prove low pressure, and neither acetazolamide nor unlocalised surgery addresses the mechanism safely.

Reference: JNNP, multidisciplinary consensus guideline for spontaneous intracranial hypotension: https://jnnp.bmj.com/content/94/10/835