American Board of Internal Medicine (ABIM) Certification Practice Exam

The combination of what symptoms would most likely indicate a serious underlying condition in headaches?

1. Unilateral headache with aura

2. Abrupt onset headache with neurologic symptoms

3. Daily headaches without other symptoms

4. Chronic headaches with significant relief from medications

The correct answer is: Abrupt onset headache with neurologic symptoms

The combination that most likely indicates a serious underlying condition in headaches is an abrupt onset headache accompanied by neurologic symptoms. This presentation raises concern for potential sinister causes such as a subarachnoid hemorrhage, intracranial hemorrhage, or other significant neurological events. Abrupt onset headaches, often described as a "thunderclap" headache, are particularly alarming, especially when they are associated with any focal neurological deficits, changes in consciousness, or other neurologic symptoms. These symptoms suggest that there may be an immediate and potentially life-threatening issue that requires rapid evaluation and treatment. In contrast, the other scenarios, while potentially concerning in their own right, do not as clearly signal a need for urgent evaluation of underlying serious pathology. For example, unilateral headache with aura can be related to migraine without indicating a serious condition, and chronic headaches that respond to medications typically are not suggestive of underlying acute pathology. Daily headaches may raise concerns about chronic conditions but generally do not suggest acute, serious problems unless there are accompanying alarming symptoms.