CCE-CBD-064

Examiner Only Information

Questions

Q1. How would you explain Olivia’s diagnosis and its underlying cause?

• Prompt: How do you explain migraine in simple terms?
• Prompt: What causes migraines, and why do triggers matter?

Q2. What red flags would prompt further investigation?

• Prompt: How do you differentiate primary headache (migraine) from secondary headache?
• Prompt: When would you order imaging or refer to neurology?

Q3. How would you manage Olivia’s acute migraine attacks?

• Prompt: What first-line medications would you prescribe?
• Prompt: How should she take them for best effect?

Q4. What preventive strategies and medications would you discuss?

• Prompt: When is migraine prophylaxis indicated?
• Prompt: What non-pharmacological strategies can help reduce attacks?

Q5. When would you consider referral to a neurologist?

• Prompt: What features suggest a need for specialist input?
• Prompt: When would you consider botulinum toxin or CGRP inhibitors?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: How would you explain Olivia’s diagnosis and its underlying cause?

The competent candidate should:

• Explain the diagnosis in simple terms:
  • “You have migraines, which are a type of headache caused by temporary changes in brain activity.”
  • “They are often triggered by stress, sleep disturbances, diet, or hormonal changes.”
• Reassure while setting expectations:
  • “Migraines are common and can be managed with a combination of medications and lifestyle changes.”
  • “While there is no cure, treatment can significantly reduce the severity and frequency of attacks.”

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Q2: What red flags would prompt further investigation?

The competent candidate should:

• Differentiate migraine from secondary headache (red flags):
  • Sudden, severe ‘thunderclap’ headache (SAH concern).
  • New onset in age >50 years (possible malignancy, GCA).
  • Progressive worsening headaches.
  • Headache with fever, neck stiffness, or altered consciousness (infection concern).
  • Focal neurological signs (stroke, space-occupying lesion).
• When to order imaging or refer to neurology:
  • CT/MRI if red flags present.
  • Neurology referral for atypical features or refractory cases.

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Q3: How would you manage Olivia’s acute migraine attacks?

The competent candidate should:

• First-line acute treatment:
  • Simple analgesia: Aspirin, ibuprofen, or paracetamol.
  • Triptans (e.g., sumatriptan 50-100 mg, taken at headache onset).
  • Antiemetics (e.g., metoclopramide or prochlorperazine) if nausea is present.
• Optimising medication use:
  • Take at headache onset for best effect.
  • Avoid overuse (>10 days per month) to prevent medication-overuse headache.

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Q4: What preventive strategies and medications would you discuss?

The competent candidate should:

• Indications for prophylactic therapy:
  • ≥4 migraine days per month.
  • Severe attacks unresponsive to acute treatment.
• First-line preventive options:
  • Beta-blockers (e.g., propranolol).
  • Amitriptyline (if associated sleep disturbances).
  • Topiramate (if weight loss is desirable).
• Lifestyle modifications:
  • Regular sleep, hydration, stress management, and exercise.
  • Dietary trigger avoidance (caffeine, alcohol, processed foods).

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Q5: When would you consider referral to a neurologist?

The competent candidate should:

• Neurology referral if:
  • Red flags or focal neurological deficits.
  • Refractory migraine despite trialling ≥2 preventive medications.
  • Suspected hemiplegic or vestibular migraine.
• Consider specialist treatments for refractory cases:
  • Botulinum toxin injections for chronic migraine.
  • CGRP monoclonal antibodies (erenumab, fremanezumab) if PBS criteria met.

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SUMMARY OF A COMPETENT ANSWER

• Clearly explains migraine, its triggers, and treatment options.
• Recognises red flags requiring imaging or neurology referral.
• Prescribes evidence-based acute treatments (triptans, antiemetics).
• Discusses lifestyle modifications and preventive therapies.
• Identifies refractory cases needing advanced treatment or referral.

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PITFALLS

• Failing to rule out secondary causes of headache (e.g., SAH, GCA, tumour).
• Overprescribing analgesics, leading to medication-overuse headache.
• Not offering preventive therapy when indicated.
• Neglecting lifestyle advice and non-pharmacological strategies.

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REFERENCES

• RACGP Migraine Management Guidelines
• National Institutes of Health on Neurology (Migraine)
• PBS Listing for CGRP Inhibitors

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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 Clearly explains migraine, triggers, and treatment options.

2. Clinical Information Gathering and Interpretation

2.1 Identifies red flags and appropriate investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates migraine from other headache syndromes.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate acute and preventive treatments.

5. Preventive and Population Health

5.2 Advises on lifestyle modifications and trigger management.

6. Professionalism

6.3 Engages in shared decision-making with the patient.

7. General Practice Systems and Regulatory Requirements

7.2 Ensures correct prescribing under PBS guidelines.

9. Managing Uncertainty

9.1 Recognises when further assessment or neurology referral is needed.

10. Identifying and Managing the Patient with Significant Illness

10.3 Detects serious neurological conditions requiring escalation.

Competency at Fellowship Level

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