10.3 Headache & Facial Pain

ABIM Internal Medicine Exam

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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy

0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan

2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

5 Chapter 4: Infectious Disease (9% of Exam)

4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections

6 Chapter 5: Pulmonary Disease (9% of Exam)

5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)

6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease

8 Chapter 7: Hematology (6% of Exam)

7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

9 Chapter 8: Medical Oncology (6% of Exam)

8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care

10 Chapter 9: Nephrology & Urology (6% of Exam)

9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

11 Chapter 10: Neurology (4% of Exam)

10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders

12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)

11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health

13 Chapter 12: Dermatology (3% of Exam)

12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease

14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

10.3 Headache & Facial Pain

Key Takeaways Explain This Topic AI

Primary headache, cluster headache, and secondary headache and facial pain are the enumerated blueprint topics.

Red flags including thunderclap onset, new headache after age 50, positional change, fever, immunosuppression, cancer and focal deficits mandate imaging.

Triptans are contraindicated in uncontrolled hypertension and in established coronary or cerebrovascular disease.

Medication overuse headache develops with frequent use of acute agents and requires withdrawal of the overused drug.

New headache with jaw claudication and visual symptoms in a patient over 50 requires immediate corticosteroids for suspected giant cell arteritis.

Last updated: August 2026

Neurological disorders encompassing headache syndromes, epileptic seizures, and movement disorders constitute a major proportion of outpatient internal medicine encounters and inpatient neurology consults. Mastery of pharmacotherapy contraindications, status epilepticus emergency protocols, and the clinical features of neurodegenerative movement disorders is essential for the ABIM exam.

1. Primary & Secondary Headache Disorders

Headaches are categorized as primary (benign neurovascular syndromes) or secondary (manifestations of underlying systemic, structural, or life-threatening pathology).

Comparison of Primary Headache Syndromes

Headache Type Pain Characteristics & Location Associated Clinical Features Acute Abortive Pharmacotherapy Evidence-Based Preventive Therapy

Migraine Unilateral (60-70%), pulsating / throbbing, moderate-to-severe intensity, aggravated by physical activity (walking, climbing stairs), lasts 4-72 hours Nausea, vomiting, photophobia, phonophobia ; +/- aura (scintillating scotoma, zig-zag fortification spectra, sensory paresthesias evolving over 5-20 min, lasting <60 min) Mild/Mod: NSAIDs, Acetaminophen, Excedrin; Mod/Severe: Triptans (Sumatriptan, Zolmitriptan); Gepants (Ubrogepant, Rimegepant); Lasmiditan (5-HT 1F agonist) Indicated if >=4 days/month or severe disability: ; - Beta-blockers (Propranolol, Metoprolol); - Anticonvulsants (Topiramate, Divalproex); - TCAs (Amitriptyline); - CGRP mAbs (Erenumab, Galcanezumab, Fremanezumab); - Botox (for chronic migraine >=15 days/mo)

Tension-Type Headache Bilateral, pressing / tightening "band-like" non-pulsating pain, mild-to-moderate intensity, lasts 30 min to 7 days, NOT aggravated by physical activity Pericranial muscle tenderness; NO nausea or vomiting ; no more than one of photophobia or phonophobia NSAIDs (Ibuprofen, Naproxen), Acetaminophen, Aspirin Amitriptyline (first-line), Mirtazapine, behavioral therapy, stress management

Cluster Headache Strictly unilateral, excruciating periorbital / retro-orbital / temporal pain , sharp / piercing / "hot poker", lasts 15-180 min, occurs in cyclical bouts / clusters (1-8 attacks/day, often nocturnal) Ipsilateral cranial autonomic signs: conjunctival injection, lacrimation, rhinorrhea, nasal congestion, eyelid edema, miosis, ptosis ( Horner syndrome ), severe agitation / pacing (unlike migraineurs who lie in a dark quiet room) 1. 100% High-Flow Oxygen (12-15 L/min via non-rebreather mask for 15-20 min); 2. Subcutaneous Sumatriptan (6 mg SC) First-line: Verapamil (high dose: 240-960 mg daily in divided doses; monitor PR interval on serial ECGs); Prednisone bridge taper ; Galcanezumab (300 mg SC)

Medication Overuse Headache (MOH) Chronic daily or near-daily dull, diffuse headache present on awakening Patient with pre-existing migraine or tension headache regularly taking acute abortive meds >10-15 days/month for >3 months Discontinue / taper overused acute medication; initiate bridge therapy (NSAID/prednisone taper) Early initiation of effective non-overused prophylactic agent (e.g., CGRP mAb, Topiramate, Amitriptyline)

Migraine Pharmacology Deep-Dive

Triptans (5-HT 1B/1D Receptor Agonists):

Mechanism: Cause vasoconstriction of painfully distended meningeal and dural blood vessels and presynaptically inhibit the release of pro-inflammatory neuropeptides (CGRP, substance P) from trigeminal perivascular nerves.

Critical Contraindications: Coronary artery disease (CAD), history of myocardial infarction, coronary vasospasm (Prinzmetal angina), stroke or TIA, peripheral arterial disease, uncontrolled hypertension, and hemiplegic or basilar-type migraine .

Small-Molecule CGRP Receptor Antagonists ("Gepants"):

Agents: Ubrogepant (50-100 mg) and Rimegepant (75 mg orally disintegrating tablet).

Clinical Utility: Extremely effective acute abortive agents that do not cause vasoconstriction ; safe in patients with vascular disease or contraindications to triptans.

5-HT 1F Receptor Agonist (Lasmiditan):

Selectively targets the 5-HT 1F receptor without vasoconstrictive activity. Causes central sedation; patients must be advised not to drive or operate machinery for at least 8 hours after ingestion.

Preventive Pharmacotherapies & Adverse Effect Profiles:

Topiramate: Causes carbonic anhydrase inhibition. Side effects: weight loss , cognitive slowing / word-finding difficulty ("Dopamax"), paresthesias, metabolic acidosis, nephrolithiasis (calcium phosphate stones), and acute angle-closure glaucoma.

Divalproex Sodium / Valproic Acid: Causes weight gain , tremor, alopecia, hepatotoxicity, pancreatitis, and severe teratogenicity (neural tube defects, craniofacial defects, cognitive deficits) ; strictly avoided in women of childbearing potential.

Amitriptyline: Tricyclic antidepressant. Side effects: sedation, weight gain, xerostomia, urinary retention, constipation, and QTc prolongation.

CGRP Pathway Monoclonal Antibodies: Erenumab (targets CGRP receptor; risk of severe constipation and hypertension), Galcanezumab , Fremanezumab , Eptinezumab (target CGRP ligand). Administered monthly or quarterly SC/IV; highly effective with minimal systemic organ toxicities.

Secondary Headaches: Red Flags & Idiopathic Intracranial Hypertension

"SNOOP4" Red Flag Criteria Mandating Neuroimaging (Brain MRI):

S — Systemic symptoms (fever, night sweats, weight loss) or systemic illness (known malignancy, HIV/AIDS, immunosuppression).

N — Neurologic signs or focal deficits (cranial nerve palsies, weakness, sensory loss, altered mental status).

O — Onset sudden ("thunderclap" headache reaching peak <1 min -> rules out SAH, RCVS, venous sinus thrombosis).

O — Older age at onset (>50 years -> rules out giant cell / temporal arteritis, intracranial mass lesion).

P4 — P attern change or progressive headache; P apilledema on funduscopy; P ositional headache (worse supine -> elevated ICP; worse upright -> intracranial hypotension / CSF leak); P recipitated by Valsalva, coughing, or exercise.

Idiopathic Intracranial Hypertension (IIH / Pseudotumor Ceredri):

Demographics: Overweight / obese women of childbearing age (20-45 years). Associated with tetracyclines (doxycycline, minocycline) , isotretinoin , excess Vitamin A , and growth hormone .

Clinical Presentation: Daily generalized headache, transient visual obscurations (brief dimming or loss of vision lasting seconds with postural changes), pulsatile synchronous tinnitus ("whooshing" sound in ears), horizontal diplopia from unilateral or bilateral cranial nerve VI (abducens) palsy , and bilateral papilledema .

Diagnostic Criteria (Modified Dandy):

Symptoms and signs of elevated intracranial pressure without focal neurological deficits (except CN VI palsy).

Brain MRI with MR Venography (MRV): Normal brain parenchyma (rules out space-occupying mass and cerebral venous sinus thrombosis); classic secondary signs include empty sella turcica , flattening of the posterior globe/sclera, and distension of perioptic subarachnoid space.

Lumbar Puncture: Elevated opening pressure ( > 250 mm H2O in adults, >280 in children) with completely normal CSF biochemical, cytological, and microbiological composition.

Management:

Weight loss and low-sodium diet (mandatory long-term intervention).

Acetazolamide (1 to 4 g/day): First-line medical therapy; carbonic anhydrase inhibitor that reduces choroid plexus CSF production.

Topiramate: Second-line / adjunctive agent (promotes weight loss and weak carbonic anhydrase inhibition).

Surgical Intervention: Optic nerve sheath fenestration (ONSF) or CSF diversion (ventriculoperitoneal / lumboperitoneal shunt) indicated for medically refractory disease or progressive, permanent visual field loss (monitored by serial automated Humphrey visual field testing).

Loading diagram... Stepped Emergency Management Protocol for Convulsive Status Epilepticus

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