CCE-CE-064

CASE INFORMATION

Case ID: CCE-MIG-01
Case Name: Jessica Carter
Age: 32
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: N89 – Migraine

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to gather relevant information about symptoms and concerns
1.2 Provides clear and empathetic explanations regarding the diagnosis and management plan
2. Clinical Information Gathering and Interpretation2.1 Takes a comprehensive headache history, including triggers and associated symptoms
2.2 Rules out secondary headache red flags (e.g., thunderclap headache, neurological deficits)
3. Diagnosis, Decision-Making and Reasoning3.1 Identifies clinical features of migraine and differentiates from other headache types
3.2 Recognises red flags requiring urgent referral (e.g., subarachnoid haemorrhage, space-occupying lesion)
4. Clinical Management and Therapeutic Reasoning4.1 Develops an evidence-based acute and preventive migraine management plan
4.2 Considers pharmacological and non-pharmacological treatment options
5. Preventive and Population Health5.1 Provides education on migraine triggers and lifestyle modifications
6. Professionalism6.1 Demonstrates patient-centred care and acknowledges the impact of migraines on daily life
7. General Practice Systems and Regulatory Requirements7.1 Ensures appropriate follow-up and medication safety monitoring
8. Procedural Skills8.1 Performs appropriate neurological examination if indicated
9. Managing Uncertainty9.1 Recognises when further investigation (e.g., imaging) is required for atypical headache presentations
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies cases requiring urgent intervention, such as new-onset severe headache in pregnancy or with focal neurological deficits

CASE FEATURES

  • Young woman with recurrent severe headaches, worsening over the past six months.
  • Classic migraine features: Unilateral, throbbing, associated with nausea and photophobia.
  • Stress and poor sleep identified as possible triggers.
  • No red flag symptoms, but headaches are affecting work and quality of life.
  • Needs assessment of migraine severity, acute and preventive treatment options.
  • Requires education on lifestyle modifications and when to seek further medical care.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

  1. Take an appropriate history.
  2. Outline the differential diagnosis and key investigations required.
  3. Address the patient’s concerns.
  4. Develop a safe and patient-centred management plan.

SCENARIO

Jessica Carter, a 32-year-old marketing professional, presents with recurrent severe headaches that have worsened over the past six months. The headaches occur approximately 2–3 times per month, last several hours to a full day, and are throbbing and mostly unilateral (left-sided).

She experiences nausea, photophobia, and phonophobia during the headaches and prefers to rest in a dark, quiet room until they resolve. Ibuprofen provides partial relief, but she often misses work due to the severity of the pain.

PATIENT RECORD SUMMARY

Patient Details

Name: Jessica Carter
Age: 32
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Ibuprofen 400 mg PRN (partial relief for headaches)

Past History

  • Occasional migraines since early 20s, now increasing in frequency
  • No history of stroke, epilepsy, or significant neurological conditions

Social History

  • Works in a high-pressure marketing job, frequent deadlines
  • No illicit drug use, no recent significant alcohol consumption

Family History

  • Mother had migraines in her 30s, improved after menopause

Smoking

  • Non-smoker

Alcohol

  • Drinks occasionally, no binge drinking

Vaccination and Preventative Activities

Up to date with routine vaccinations

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, my headaches are getting worse, and I feel like they’re starting to take over my life. I need something stronger to stop them.”

General Information

You are Jessica Carter, a 32-year-old marketing professional who has been experiencing migraine headaches for over 10 years, but in the past six months, they have become more frequent and severe.

Previously, you would have one or two migraines every few months, but now you get two to three migraines per month, and sometimes even weekly attacks. Each episode lasts several hours to a full day, and you are often unable to work or go about your normal routine.

Specific Information

(Reveal only when asked)

Background Information

The headaches are always throbbing, usually on the left side, and feel like a pounding pain behind your eye. The pain worsens with movement, and you find it hard to concentrate. You also experience nausea, sensitivity to light and noise, and a general sense of exhaustion.

When a migraine comes on, you prefer to lie in a dark, quiet room and try to sleep. Ibuprofen helps slightly, but doesn’t fully stop the pain.

You’re here today because you’re frustrated with how migraines are affecting your work and life, and you want to know if there’s a stronger treatment or a way to stop them from happening so often.

Headache Characteristics

  • The migraines start gradually, building up over an hour or two.
  • You experience throbbing pain, mainly on the left side of your head, sometimes behind the left eye.
  • The pain is moderate to severe, making it hard to function.
  • You feel nauseous but rarely vomit.
  • The headaches worsen with bright lights, loud noises, and movement.
  • You don’t get an aura before the headache starts (no flashing lights or visual changes).

Triggers and Lifestyle Factors

  • Stress and poor sleep seem to trigger migraines.
  • You work in a high-pressure marketing job, and deadlines make things worse.
  • You sleep 5–6 hours per night, and your sleep is often interrupted.
  • You drink 1–2 coffees per day but don’t have excessive caffeine intake.
  • You don’t drink alcohol often, and migraines don’t seem linked to alcohol.
  • Your menstrual cycle doesn’t seem to affect your migraines.
  • You haven’t had any recent head injuries, infections, or neurological conditions.

Concerns and Expectations

  • You are worried that something serious might be causing these headaches, like a brain tumour or another medical condition.
  • You are frustrated that migraines are affecting your ability to work.
  • You want to know if you need a brain scan to rule out serious causes.
  • You’re interested in trying stronger medications to stop a migraine quickly.
  • You want to know if there’s something you can take daily to prevent migraines.

Emotional Cues & Body Language

  • You appear tired and frustrated, rubbing your temples occasionally.
  • You seem worried when discussing whether this could be something serious.
  • You become more engaged when treatment options are discussed.
  • If the doctor dismisses your concerns, you push for a more detailed explanation or stronger medication options.

Questions for the Candidate (Ask Naturally During the Consultation)

  1. “Do you think this is just migraines, or could it be something more serious?”
  2. “Should I get a brain scan to check for anything dangerous?”
  3. “Is there a medication that can stop a migraine quickly?”
  4. “Can I take something daily to prevent them?”
  5. “What can I do to reduce the number of migraines I get?”
  6. “Are there any natural treatments or lifestyle changes that actually work?”
  7. “How long will it take before I see improvement if I start new treatment?”

Response to Advice Given by the Candidate

  • If the candidate explains migraines clearly, you feel reassured.
  • If they rule out serious causes but still take your concerns seriously, you feel more confident in their advice.
  • If they suggest lifestyle changes, you express willingness to try but need clear guidance.
  • If they suggest preventive medications, you ask about side effects and how long it takes to work.
  • If the candidate does not offer a structured plan, you feel frustrated and push for more options.

Final Thought

If the candidate explains the condition well, reassures you, and provides a structured treatment plan, you feel hopeful and ready to follow their advice. If they are vague, dismissive, or fail to acknowledge how much migraines are affecting your life, you leave feeling frustrated and unsure about what to do next.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including headache characteristics, triggers, and associated symptoms.

The competent candidate should:

  • Elicit a detailed headache history, including:
    • Onset and progression (gradual, worsening over six months).
    • Location (unilateral, left-sided).
    • Duration (several hours to a full day).
    • Quality (throbbing, worsens with movement).
    • Associated symptoms (nausea, photophobia, phonophobia).
    • Aura presence (none reported).
  • Identify potential triggers:
    • Stress, poor sleep, caffeine intake.
    • Menstrual cycle patterns (not a factor in this case).
  • Assess functional impact:
    • Missed workdays and difficulty concentrating.
  • Review medication use:
    • Overuse of analgesics leading to medication-overuse headache.

Task 2: Identify key clinical features and assess for red flags requiring further investigation.

The competent candidate should:

  • Recognise features consistent with migraine:
    • Recurrent, unilateral, throbbing headaches.
    • Photophobia, phonophobia, nausea.
    • Relief with rest in a dark room.
  • Assess for red flag symptoms requiring urgent referral:
    • New onset in patient >50 years.
    • Sudden “thunderclap” onset (suggesting subarachnoid haemorrhage).
    • Progressive worsening, focal neurological symptoms.
    • Seizures, personality change, or signs of raised intracranial pressure.
  • Determine the need for neuroimaging (MRI or CT scan):
    • Not required if headache follows a typical migraine pattern and there are no red flags.

Task 3: Explain the likely diagnosis, management options, and when further care is needed.

The competent candidate should:

  • Explain the diagnosis in simple terms:
    • Likely migraine, a neurological condition causing severe headaches with associated symptoms.
  • Reassure the patient:
    • No red flag symptoms → no need for urgent imaging.
  • Outline treatment goals:
    • Relieve acute attacks quickly.
    • Reduce migraine frequency and severity.
  • Discuss acute treatment options:
    • Triptans (e.g., sumatriptan) for moderate-severe attacks.
    • NSAIDs or paracetamol for milder migraines.
    • Anti-nausea medications if required (e.g., metoclopramide).
  • Discuss preventive strategies:
    • Lifestyle modifications (stress reduction, sleep hygiene).
    • Preventive medications if migraines are frequent (e.g., propranolol, amitriptyline).

Task 4: Develop a safe, evidence-based management plan, including acute treatment, prevention, and follow-up.

The competent candidate should:

  • Initiate an acute treatment plan:
    • Triptan therapy (e.g., sumatriptan 50 mg at onset, repeat in 2 hours if needed).
    • Ibuprofen 400 mg as an alternative.
    • Metoclopramide for nausea if needed.
  • Introduce preventive strategies:
    • Identify and avoid triggers (stress, poor sleep).
    • Consider daily preventive medication if >4 attacks per month.
  • Educate on medication overuse headache:
    • Avoid using painkillers >10 days per month.
  • Arrange follow-up:
    • Review in 4 weeks to assess treatment response.
    • Consider referral to a neurologist if no improvement.

SUMMARY OF A COMPETENT ANSWER

  • Takes a comprehensive headache history, identifying migraine characteristics.
  • Recognises features suggestive of primary migraine and excludes red flag symptoms.
  • Provides reassurance, explaining why imaging is unnecessary.
  • Develops an individualised treatment plan, including acute and preventive management.
  • Educates on medication overuse and lifestyle modifications.
  • Ensures structured follow-up to monitor symptom control and adjust treatment.

PITFALLS

  • Failing to rule out red flag symptoms, leading to missed serious diagnoses.
  • Over-relying on imaging in a patient with a clear migraine history.
  • Not discussing lifestyle modifications, limiting long-term migraine control.
  • Neglecting preventive treatment options, especially in frequent migraines.
  • Not addressing medication overuse, which could worsen headaches.
  • Lack of structured follow-up, delaying treatment adjustments.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive headache history, including triggers and associated symptoms.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies clinical features of migraine and differentiates from other headache types.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based acute and preventive migraine management plan.

5. Preventive and Population Health

5.1 Provides education on migraine triggers and lifestyle modifications.

6. Professionalism

6.1 Demonstrates patient-centred care and acknowledges the impact of migraines on daily life.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate follow-up and medication safety monitoring.

8. Procedural Skills

8.1 Performs appropriate neurological examination if indicated.

9. Managing Uncertainty

9.1 Recognises when further investigation is required for atypical headache presentations.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies cases requiring urgent intervention, such as new-onset severe headache in pregnancy or with focal neurological deficits.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD