EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for Peter’s headache?

• Prompt: How would you differentiate between primary and secondary headaches?
• Prompt: What are the red flags that would change your approach?

Q2. What features in Peter’s presentation make a serious secondary cause less likely?

• Prompt: How does the absence of certain symptoms guide your management?
• Prompt: When would you consider neuroimaging?

Q3. How would you explain your assessment and diagnosis to Peter in a reassuring but informative way?

• Prompt: What key messages should you communicate about his condition?
• Prompt: How would you address his concerns about a brain tumour?

Q4. Outline your initial management plan for Peter.

• Prompt: What pharmacological and non-pharmacological approaches would you recommend?
• Prompt: How would you involve lifestyle modifications?

Q5. When should Peter return for a follow-up review, and what signs would warrant urgent referral?

• Prompt: How do you safety-net for possible deterioration?
• Prompt: What role does shared decision-making play in his ongoing care?

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This case assesses a candidate’s ability to:

1. Differentiate between primary vs secondary headache causes.
2. Recognise red flag symptoms and decide when to escalate care.
3. Reassure and educate a concerned patient effectively.
4. Implement a structured headache management plan.
5. Use appropriate safety-netting and follow-up strategies.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for Peter’s headache?

• Primary headaches
  • Tension-type headache (most likely): Bilateral, pressing/tightening quality, no red flags
  • Migraine: Usually unilateral, pulsatile, associated with photophobia, phonophobia, nausea
  • Cluster headache: Rare, unilateral, autonomic symptoms (lacrimation, rhinorrhoea)
• Secondary headaches
  • Medication overuse headache: Chronic analgesic use
  • Cervicogenic headache: Related to poor posture, worsens with neck movement
  • Hypertensive headache: Severe, pulsatile, associated with very high BP
  • Temporal arteritis: Age >50, scalp tenderness, jaw claudication, ESR/CRP elevated
  • Raised intracranial pressure (ICP): Progressive, worse in morning/lying down, papilloedema
  • Subarachnoid haemorrhage: Thunderclap onset, meningism, altered consciousness
  • Meningitis/encephalitis: Fever, photophobia, neck stiffness

A competent candidate prioritises tension-type headache while excluding red flags.

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Q2: What features in Peter’s presentation make a serious secondary cause less likely?

• No red flags:
  • No sudden onset (“thunderclap” headache) → unlikely subarachnoid haemorrhage
  • No progressive worsening → less likely tumour or raised ICP
  • No neurological deficits → rules out stroke, mass effect
  • No fever, neck stiffness → unlikely meningitis
• Headache pattern:
  • Bilateral, dull, pressure-like → typical for tension-type headache
  • Improves with simple analgesia → not suggestive of severe pathology
• Patient factors:
  • No significant past medical history
  • No recent trauma or significant medication use

A competent candidate uses pattern recognition and absence of red flags to justify reassurance.

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Q3: How would you explain your assessment and diagnosis to Peter in a reassuring but informative way?

• Acknowledge concerns: “I understand that persistent headaches can be worrying, especially when they’re new.”
• Explain likely diagnosis: “Based on your symptoms, it is most likely a tension-type headache, which is common in people under stress.”
• Address fears of serious conditions: “Your symptoms don’t suggest anything dangerous like a brain tumour or aneurysm.”
• Provide education: “These headaches are often related to stress, posture, or screen time.”
• Discuss next steps:
  • “We’ll work on lifestyle modifications first.”
  • “If symptoms persist or worsen, we may consider further tests such as an MRI.”

A competent candidate balances reassurance with medical reasoning, ensuring patient engagement.

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Q4: Outline your initial management plan for Peter.

• Non-pharmacological strategies:
  • Stress management: Relaxation techniques, regular breaks at work
  • Postural adjustments: Ergonomic workspace setup, regular stretching
  • Lifestyle: Hydration, sleep hygiene, exercise
• Pharmacological options (if required):
  • First-line: Simple analgesia (paracetamol or ibuprofen, limited use)
  • Avoid overuse: Educate on medication-overuse headache risk
• Follow-up plan:
  • Review in 2 weeks if persistent symptoms
  • Safety-net for new or worsening symptoms (e.g., weakness, visual loss, severe headache)

A competent candidate ensures a holistic approach, prioritising lifestyle modifications and safety netting.

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Q5: When should Peter return for a follow-up review, and what signs would warrant urgent referral?

• Routine follow-up in 2 weeks to reassess symptoms
• Urgent review if:
  • Sudden severe headache (“thunderclap”)
  • Neurological deficits (weakness, numbness, slurred speech)
  • Visual changes (blurry vision, double vision, papilloedema)
  • Persistent worsening despite treatment
• Escalation pathway:
  • Urgent GP review → Consider neuroimaging (MRI/CT)
  • Referral to neurologist if chronic or atypical presentation

A competent candidate implements structured follow-up with clear safety-netting for serious conditions.

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SUMMARY OF A COMPETENT ANSWER

• Uses a structured approach to differential diagnosis, distinguishing primary vs secondary headaches.
• Demonstrates clinical reasoning, ruling out serious conditions based on history and examination.
• Communicates effectively, providing clear, empathetic explanations that address patient concerns.
• Develops an evidence-based management plan, prioritising non-pharmacological strategies.
• Implements appropriate safety-netting, outlining follow-up and red flag symptoms.

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PITFALLS

• Failing to rule out red flag symptoms: Missing signs of serious conditions like meningitis or raised ICP.
• Over-reliance on pharmacological management: Ignoring lifestyle modifications and stress management.
• Inadequate reassurance and patient education: Not addressing the patient’s fears about a serious cause.
• Neglecting a follow-up plan: Not advising on review and escalation criteria for persistent symptoms.

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REFERENCES

• RACGP – RACGP Headache Guidelines
• GP Exams – Headache

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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 Communicates effectively and appropriately to provide quality care.
1.3 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information effectively.
2.3 Identifies red flags and important diagnostic features.

3. Diagnosis, Decision-Making and Reasoning

3.1 Applies a structured approach to making a diagnosis.
3.3 Identifies and manages urgent and serious conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements an appropriate management plan.
4.3 Provides patient-centered management.

5. Preventive and Population Health

5.1 Applies preventive care strategies relevant to the patient’s condition.

6. Professionalism

6.2 Practices ethically and legally, respecting patient autonomy.

7. General Practice Systems and Regulatory Requirements

7.1 Uses appropriate healthcare systems and referral pathways.

8. Procedural Skills

8.1 Selects and performs appropriate investigations.

9. Managing Uncertainty

9.1 Identifies and manages clinical uncertainty.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages life-threatening conditions.

Competency at Fellowship Level

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