EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Emily’s headache?

• Prompt: What is the most likely diagnosis and why?
• Prompt: What other conditions should be considered?

Q2. What red flags would indicate the need for urgent referral or further investigations?

• Prompt: What features suggest a serious or secondary headache cause?
• Prompt: What initial investigations would you consider if red flags were present?

Q3. How would you manage Emily’s tension-type headache?

• Prompt: What pharmacological and non-pharmacological treatments would you recommend?
• Prompt: When would you consider specialist referral?

Q4. Emily is worried about a brain tumour. How would you counsel her?

• Prompt: How do you explain her symptoms and reassure her?
• Prompt: What advice would you provide about when to seek further review?

Q5. What preventive strategies can Emily implement to reduce her headache frequency?

• Prompt: How can she modify her lifestyle to prevent headaches?
• Prompt: What role do stress management, posture, and caffeine intake play?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for Emily’s headache?

Emily’s most likely diagnosis is tension-type headache (TTH), given the bilateral, band-like pressure, absence of nausea, vomiting, or neurological symptoms, and association with stress and muscle tension.

Key Differential Diagnoses:

1. Tension-Type Headache (Most Likely) – Mild to moderate, non-pulsatile, bilateral headache, worsened by stress and muscle tension, with no associated nausea, photophobia, or aura.
2. Migraine without Aura – Consider if unilateral, pulsatile headache lasting 4–72 hours, associated with nausea, photophobia, and phonophobia.
3. Medication Overuse Headache – If frequent analgesic use (≥15 days/month of paracetamol or NSAIDs).
4. Cervicogenic Headache – If associated with neck stiffness and worsens with specific head movements.
5. Secondary Headache (e.g., Brain Tumour, Giant Cell Arteritis, Subarachnoid Haemorrhage) – Red flag symptoms must be excluded.

Further assessment, including headache triggers, impact on function, and red flags, will refine the diagnosis.

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Q2: What red flags would indicate the need for urgent referral or further investigations?

Red flags requiring urgent referral:

• Sudden onset (“thunderclap headache”) – Consider subarachnoid haemorrhage (SAH).
• New headache in age >50 – Concern for temporal arteritis or malignancy.
• Neurological deficits (focal weakness, diplopia, altered consciousness) – Consider stroke or brain tumour.
• Progressive headache worsening over weeks to months – Raises concern for raised intracranial pressure (ICP) or malignancy.
• Headache with fever, neck stiffness, photophobia – Suggests meningitis.

Recommended Investigations (if red flags present):

• CT Brain (urgent if SAH suspected).
• MRI Brain (if concern for malignancy or structural cause).
• ESR/CRP (if temporal arteritis suspected in age >50).
• LP (if meningitis or SAH suspected but CT negative).

Emily has no red flags, so diagnosis is clinical, and imaging is not required.

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Q3: How would you manage Emily’s tension-type headache?

1. Pharmacological Management (Symptomatic Relief):

• Paracetamol 1g PRN – First-line.
• NSAIDs (Ibuprofen 400mg PRN) – If no contraindications.
• Avoid codeine-containing analgesics – Risk of medication overuse headache.

2. Non-Pharmacological Management:

• Regular exercise (e.g., walking, yoga) – Reduces muscle tension.
• Physiotherapy & postural correction – If muscle tightness contributes.
• Cognitive Behavioural Therapy (CBT) or mindfulness – If stress-related.

3. Preventive Therapy (If Frequent or Chronic Headaches):

• Amitriptyline 10–25mg nocte – First-line for chronic TTH.
• Gabapentin or topiramate – If refractory.

4. Follow-Up:

• Review in 4–6 weeks – Assess headache frequency and treatment response.
• Refer to neurology if headaches worsen or atypical features develop.

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Q4: Emily is worried about a brain tumour. How would you counsel her?

1. Acknowledge Concerns & Provide Reassurance
   • “Many patients worry about brain tumours when they have headaches, but your symptoms do not suggest a serious underlying condition.”
   • “You have no red flags, no neurological deficits, and a clear stress-related pattern, which all support tension-type headaches.”
2. Explain the Diagnosis Clearly
   • “Your headaches are caused by muscle tension and stress, not by a brain tumour.”
   • “They are common in people with high stress levels or poor posture.”
3. Educate on When to Seek Medical Review
   • “If you develop severe, sudden onset headache, neurological symptoms, or worsening over time, seek urgent review.”
   • “Otherwise, these headaches can be well managed with lifestyle adjustments and occasional analgesics.”

Clear explanations help reduce health anxiety and promote self-management.

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Q5: What preventive strategies can Emily implement to reduce her headache frequency?

1. Lifestyle Modifications:
   • Improve sleep hygiene – Maintain consistent sleep schedule.
   • Regular exercise – Reduces stress and improves muscle relaxation.
   • Hydration and balanced diet – Prevents dehydration headaches.
2. Stress Management:
   • Mindfulness or CBT-based techniques.
   • Limit caffeine intake (reduce from 3–4 cups to ≤2 per day).
3. Ergonomic & Postural Adjustments:
   • Adjust desk height and chair position to reduce neck strain.
   • Take frequent breaks from screen use.
4. Headache Diary:
   • Helps identify triggers and track headache patterns.

Emily can significantly reduce headache frequency through lifestyle and stress management.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, distinguishing tension-type headache from migraine and serious secondary causes.
• Identification of red flags, ensuring urgent referral if needed.
• Structured, evidence-based management plan, including pharmacological and non-pharmacological strategies.
• Clear patient-centred counselling, addressing brain tumour concerns and appropriate reassurance.
• Preventive strategies, including postural adjustments, exercise, hydration, and stress reduction techniques.

PITFALLS

• Failing to assess for red flags, missing serious conditions like SAH or brain tumour.
• Overprescribing analgesics, leading to medication overuse headache.
• Not addressing lifestyle factors, such as stress, sleep, and posture.
• Dismissing patient concerns, rather than providing structured reassurance.
• Lack of follow-up planning, missing progression to chronic headache disorder.

REFERENCES

• RACGP – RACGP Guidelines on Management of chronic headache
• GP Exams – Tension 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 Takes a structured headache history, including triggers and impact on daily life.
1.2 Provides clear explanations about the diagnosis, management, and red flags requiring further review.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a systematic neurological and musculoskeletal examination.
2.2 Differentiates between primary and secondary headache causes.

3. Diagnosis, Decision-Making and Reasoning

3.1 Diagnoses tension-type headache based on clinical features.
3.2 Determines when further investigations or specialist referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate management plan, including pharmacological and non-pharmacological strategies.
4.2 Provides lifestyle modification strategies to prevent recurrence.

Competency at Fellowship Level

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