COMAT Neurology Final Exam Prep (2026-2027) Exam
Blueprint Overview (Based on NBOME COMAT
Neurology) QUESTIONS AND ANSWERS ALREADY
GRADED A+
Core Domains & Weighting:
• Headache, Pain, & Demyelinating Disease: 17-21%
• Stroke, Seizure, & Movement Disorders: 17-21%
• Mental Status, Sleep, & Other Neurologic Disorders: 15-19%
• Spinal Cord, Peripheral Nerve, & Neuromuscular Junction: 15-19%
• Infection, Oncology, & Pediatric Neurology: 10-14%
• Trauma, Toxicology, & Neuroanatomy: 10-14%
Section 1: Headache & Pain Disorders (Questions 1-15)
Q1. A 35-year-old woman presents with recurrent episodes of unilateral, throbbing headache
lasting 6-12 hours, associated with nausea, photophobia, and phonophobia. She reports that
the headaches worsen with routine physical activity. What is the most appropriate acute
treatment?
A) Sumatriptan 50-100 mg orally at onset
B) Naproxen 500 mg twice daily for prevention
C) Propranolol 80 mg daily
D) Topiramate 25 mg daily
Answer: A – Sumatriptan 50-100 mg orally at onset
Rationale: The presentation is classic for migraine without aura . First-line acute treatment for
moderate-to-severe migraine includes triptans (sumatriptan, rizatriptan, eletriptan). Triptans are
,most effective when taken at the onset of headache. NSAIDs are appropriate for mild migraines.
Propranolol and topiramate are preventive medications, not acute treatments.
Q2. A 45-year-old man reports episodic, severe, unilateral periorbital pain lasting 30-60
minutes, occurring 3 times per day for the past week. Associated symptoms include ipsilateral
conjunctival injection, lacrimation, and nasal congestion. During episodes, he paces the room.
What is the most appropriate acute treatment?
A) Oral sumatriptan
B) High-flow oxygen (100% at 12-15 L/min)
C) Intravenous valproate
D) Oral prednisone
Answer: B – High-flow oxygen (100% at 12-15 L/min)
Rationale: Cluster headache is characterized by severe, unilateral orbital/periorbital pain with
autonomic features and restlessness/agitation . High-flow oxygen (100% via non-rebreather
mask at 12-15 L/min for 15-20 minutes) is the most effective acute treatment, providing relief in
70-80% of patients. Injectable or intranasal triptans are also effective. Oral triptans are too slow.
Prednisone is used for transitional prophylaxis, not acute treatment .
Q3. A 60-year-old patient with a history of migraine presents with new-onset "thunderclap"
headache that reached maximum intensity within seconds during sexual intercourse. Neurologic
examination is normal. Non-contrast head CT is normal. What is the most appropriate next
step?
A) Discharge home with ibuprofen
B) Lumbar puncture for xanthochromia
C) Oral triptan trial
D) MRI brain without contrast
Answer: B – Lumbar puncture for xanthochromia
Rationale: Thunderclap headache (sudden, severe headache reaching peak within seconds to 1
minute) requires urgent evaluation for subarachnoid hemorrhage (SAH) even with normal non-
contrast CT . CT sensitivity for SAH is near 100% within 6 hours of onset but decreases after 6
hours . When CT is negative and suspicion remains (including sentinel headache preceding
aneurysmal SAH), lumbar puncture with xanthochromia (bilirubin from RBC breakdown) is the
next diagnostic step .
,Q4. A 25-year-old woman with a history of migraines presents with sudden-onset severe
headache, right-sided weakness, and difficulty speaking. She is on combined oral
contraceptives. What is the most appropriate next step?
A) Oral triptan
B) Stat non-contrast head CT
C) MRI brain with contrast
D) Sumatriptan injection
Answer: B – Stat non-contrast head CT
Rationale: New focal neurologic symptoms (weakness, aphasia) in a patient with migraine
(especially with aura) raise concern for stroke, particularly in the setting of oral contraceptive
use . Triptans are contraindicated in patients with focal neurologic deficits due to risk of stroke.
The initial imaging study for suspected acute stroke is non-contrast head CT to rule out
hemorrhage .
Q5. A 55-year-old woman presents with daily, bilateral, pressing/tight headache that is not
pulsatile. She describes it as a "band around the head." No nausea, photophobia, or
phonophobia. What is the most likely diagnosis?
A) Migraine without aura
B) Tension-type headache
C) Cluster headache
D) Medication-overuse headache
Answer: B – Tension-type headache
Rationale: Tension-type headache presents with bilateral, non-pulsatile, pressing/tight quality
(like a band or vise), mild to moderate intensity, no aggravation by routine activity, and no
associated nausea or aura . It may have photophobia or phonophobia but not both. Tension-
type headache is the most common headache disorder.
Q6. A patient with episodic migraine has been using triptans on 14 days per month for the past
6 months. Headache frequency has increased to 18 days per month. What is the most likely
diagnosis?
, A) Chronic migraine
B) New daily persistent headache
C) Medication-overuse headache
D) Hemicrania continua
Answer: C – Medication-overuse headache (MOH)
Rationale: Medication-overuse headache (rebound headache) develops when acute migraine
medications (triptans, opioids, butalbital, NSAIDs) are used on ≥10 days per month for ≥3
months . It presents as headache on ≥15 days per month with worsening frequency despite
medication use. Treatment requires discontinuation of the overused medication (withdrawal)
and initiation of preventive therapy .
Q7. A 70-year-old patient presents with new-onset headache, scalp tenderness, jaw
claudication, and fever. ESR is 95 mm/hr. What is the most appropriate next step?
A) MRI brain
B) Temporal artery biopsy
C) Empiric high-dose corticosteroids immediately after biopsy
D) Observation with NSAIDs
Answer: C – Empiric high-dose corticosteroids immediately after biopsy
Rationale: Giant cell arteritis (temporal arteritis) is a medical emergency due to risk of
irreversible vision loss . High-dose corticosteroids (prednisone 40-60 mg daily or IV
methylprednisolone) should be started immediately after temporal artery biopsy (ideally within
24-48 hours) without waiting for biopsy results. Biopsy may be negative despite clinical
diagnosis due to skip lesions .
Q8. A 30-year-old woman with migraine is planning pregnancy. Which preventive medication is
considered safest during pregnancy?
A) Propranolol
B) Topiramate
C) Valproate
D) Botulinum toxin
Answer: A – Propranolol
Blueprint Overview (Based on NBOME COMAT
Neurology) QUESTIONS AND ANSWERS ALREADY
GRADED A+
Core Domains & Weighting:
• Headache, Pain, & Demyelinating Disease: 17-21%
• Stroke, Seizure, & Movement Disorders: 17-21%
• Mental Status, Sleep, & Other Neurologic Disorders: 15-19%
• Spinal Cord, Peripheral Nerve, & Neuromuscular Junction: 15-19%
• Infection, Oncology, & Pediatric Neurology: 10-14%
• Trauma, Toxicology, & Neuroanatomy: 10-14%
Section 1: Headache & Pain Disorders (Questions 1-15)
Q1. A 35-year-old woman presents with recurrent episodes of unilateral, throbbing headache
lasting 6-12 hours, associated with nausea, photophobia, and phonophobia. She reports that
the headaches worsen with routine physical activity. What is the most appropriate acute
treatment?
A) Sumatriptan 50-100 mg orally at onset
B) Naproxen 500 mg twice daily for prevention
C) Propranolol 80 mg daily
D) Topiramate 25 mg daily
Answer: A – Sumatriptan 50-100 mg orally at onset
Rationale: The presentation is classic for migraine without aura . First-line acute treatment for
moderate-to-severe migraine includes triptans (sumatriptan, rizatriptan, eletriptan). Triptans are
,most effective when taken at the onset of headache. NSAIDs are appropriate for mild migraines.
Propranolol and topiramate are preventive medications, not acute treatments.
Q2. A 45-year-old man reports episodic, severe, unilateral periorbital pain lasting 30-60
minutes, occurring 3 times per day for the past week. Associated symptoms include ipsilateral
conjunctival injection, lacrimation, and nasal congestion. During episodes, he paces the room.
What is the most appropriate acute treatment?
A) Oral sumatriptan
B) High-flow oxygen (100% at 12-15 L/min)
C) Intravenous valproate
D) Oral prednisone
Answer: B – High-flow oxygen (100% at 12-15 L/min)
Rationale: Cluster headache is characterized by severe, unilateral orbital/periorbital pain with
autonomic features and restlessness/agitation . High-flow oxygen (100% via non-rebreather
mask at 12-15 L/min for 15-20 minutes) is the most effective acute treatment, providing relief in
70-80% of patients. Injectable or intranasal triptans are also effective. Oral triptans are too slow.
Prednisone is used for transitional prophylaxis, not acute treatment .
Q3. A 60-year-old patient with a history of migraine presents with new-onset "thunderclap"
headache that reached maximum intensity within seconds during sexual intercourse. Neurologic
examination is normal. Non-contrast head CT is normal. What is the most appropriate next
step?
A) Discharge home with ibuprofen
B) Lumbar puncture for xanthochromia
C) Oral triptan trial
D) MRI brain without contrast
Answer: B – Lumbar puncture for xanthochromia
Rationale: Thunderclap headache (sudden, severe headache reaching peak within seconds to 1
minute) requires urgent evaluation for subarachnoid hemorrhage (SAH) even with normal non-
contrast CT . CT sensitivity for SAH is near 100% within 6 hours of onset but decreases after 6
hours . When CT is negative and suspicion remains (including sentinel headache preceding
aneurysmal SAH), lumbar puncture with xanthochromia (bilirubin from RBC breakdown) is the
next diagnostic step .
,Q4. A 25-year-old woman with a history of migraines presents with sudden-onset severe
headache, right-sided weakness, and difficulty speaking. She is on combined oral
contraceptives. What is the most appropriate next step?
A) Oral triptan
B) Stat non-contrast head CT
C) MRI brain with contrast
D) Sumatriptan injection
Answer: B – Stat non-contrast head CT
Rationale: New focal neurologic symptoms (weakness, aphasia) in a patient with migraine
(especially with aura) raise concern for stroke, particularly in the setting of oral contraceptive
use . Triptans are contraindicated in patients with focal neurologic deficits due to risk of stroke.
The initial imaging study for suspected acute stroke is non-contrast head CT to rule out
hemorrhage .
Q5. A 55-year-old woman presents with daily, bilateral, pressing/tight headache that is not
pulsatile. She describes it as a "band around the head." No nausea, photophobia, or
phonophobia. What is the most likely diagnosis?
A) Migraine without aura
B) Tension-type headache
C) Cluster headache
D) Medication-overuse headache
Answer: B – Tension-type headache
Rationale: Tension-type headache presents with bilateral, non-pulsatile, pressing/tight quality
(like a band or vise), mild to moderate intensity, no aggravation by routine activity, and no
associated nausea or aura . It may have photophobia or phonophobia but not both. Tension-
type headache is the most common headache disorder.
Q6. A patient with episodic migraine has been using triptans on 14 days per month for the past
6 months. Headache frequency has increased to 18 days per month. What is the most likely
diagnosis?
, A) Chronic migraine
B) New daily persistent headache
C) Medication-overuse headache
D) Hemicrania continua
Answer: C – Medication-overuse headache (MOH)
Rationale: Medication-overuse headache (rebound headache) develops when acute migraine
medications (triptans, opioids, butalbital, NSAIDs) are used on ≥10 days per month for ≥3
months . It presents as headache on ≥15 days per month with worsening frequency despite
medication use. Treatment requires discontinuation of the overused medication (withdrawal)
and initiation of preventive therapy .
Q7. A 70-year-old patient presents with new-onset headache, scalp tenderness, jaw
claudication, and fever. ESR is 95 mm/hr. What is the most appropriate next step?
A) MRI brain
B) Temporal artery biopsy
C) Empiric high-dose corticosteroids immediately after biopsy
D) Observation with NSAIDs
Answer: C – Empiric high-dose corticosteroids immediately after biopsy
Rationale: Giant cell arteritis (temporal arteritis) is a medical emergency due to risk of
irreversible vision loss . High-dose corticosteroids (prednisone 40-60 mg daily or IV
methylprednisolone) should be started immediately after temporal artery biopsy (ideally within
24-48 hours) without waiting for biopsy results. Biopsy may be negative despite clinical
diagnosis due to skip lesions .
Q8. A 30-year-old woman with migraine is planning pregnancy. Which preventive medication is
considered safest during pregnancy?
A) Propranolol
B) Topiramate
C) Valproate
D) Botulinum toxin
Answer: A – Propranolol
