CCE-CE-064.1

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including headache pattern, triggers, associated symptoms, and red flags.

The competent candidate should:

• Elicit a structured headache history, including:
  • Onset and frequency (six-month history, occurring twice a month, lasting 12–24 hours).
  • Headache characteristics (throbbing, right-sided, moderate to severe intensity).
  • Associated symptoms (nausea, photophobia, phonophobia, worsened by movement).
  • Impact on daily activities (missed work, difficulty concentrating).
• Identify potential triggers:
  • Stress, poor sleep, skipped meals.
  • No clear association with alcohol or caffeine.
• Assess for red flags that warrant further investigation:
  • New-onset headache over 50 years old.
  • Sudden onset “thunderclap” headache.
  • Neurological deficits (weakness, visual disturbance, speech changes).
  • Fever, neck stiffness, or altered mental status.

Task 2: Differentiate between migraine and other headache types, identifying any red flags for secondary headache.

The competent candidate should:

• Differentiate migraine from other headache disorders:
  • Migraine – unilateral, pulsatile, nausea, photophobia, phonophobia, activity worsens symptoms.
  • Tension-type headache – bilateral, dull/pressure-like, no nausea or photophobia.
  • Cluster headache – severe, unilateral periorbital pain with autonomic features (lacrimation, nasal congestion).
  • Medication-overuse headache – daily headaches in those using analgesics frequently.
• Recognise features requiring urgent imaging:
  • New neurological deficits, sudden onset, worsening over weeks/months, systemic symptoms.
  • Jessica’s case does not suggest a secondary cause, so imaging is not routinely needed.

Task 3: Provide a diagnosis and discuss an initial management plan, including acute and preventive treatment options.

The competent candidate should:

• Explain the likely diagnosis:
  • Episodic migraine without aura based on headache characteristics.
  • Triggers such as stress, poor sleep, and irregular meals contribute to frequency.
• Acute treatment plan:
  • First-line: NSAIDs (ibuprofen) or simple analgesia (paracetamol).
  • Triptans (e.g., sumatriptan) for moderate to severe attacks.
  • Anti-emetics (metoclopramide, prochlorperazine) if nausea is significant.
  • Non-pharmacological strategies (resting in a dark, quiet room).
• Preventive treatment indications (≥4 migraines/month, significant disability, medication overuse risk):
  • Consider propranolol, amitriptyline, or topiramate if frequency worsens.
  • Lifestyle modifications as a first-line prevention strategy.

Task 4: Educate the patient on migraine triggers, lifestyle modifications, and when to seek further medical attention.

The competent candidate should:

• Discuss migraine triggers and avoidance strategies:
  • Regular meals, adequate hydration, stress management.
  • Sleep hygiene (consistent bedtime, avoiding screen exposure before sleep).
• Explain the role of a headache diary to track patterns and triggers.
• Address Jessica’s concern about imaging:
  • Reassure her that her symptoms are typical of migraine and that a brain scan is not needed unless red flags develop.
• Provide safety-netting advice:
  • Return if headaches increase in frequency/severity or if new neurological symptoms develop.

SUMMARY OF A COMPETENT ANSWER

• Takes a structured headache history, including onset, frequency, triggers, and impact.
• Differentiates migraine from secondary headaches, recognising red flags requiring urgent imaging.
• Provides a structured acute and preventive management plan, including triptans, lifestyle modifications, and headache diaries.
• Educates on non-pharmacological strategies, such as regular meals, sleep hygiene, and stress reduction.
• Addresses patient concerns about brain scans, explaining when imaging is necessary.

PITFALLS

• Failing to assess for red flags, leading to missed secondary causes of headache.
• Overprescribing triptans without addressing lifestyle modifications, risking medication-overuse headache.
• Not providing clear safety-netting advice, leading to poor follow-up and patient anxiety.
• Suggesting imaging unnecessarily, increasing healthcare costs and patient worry.
• Not discussing preventive treatment options, missing opportunities to reduce migraine burden.

REFERENCES

• RACGP Migraine and Headache Guidelines
• National Institutes of Health Neurology on Migraine Management
• Better Health Channel on Migraine Information
• Australian Prescriber on Acute and Preventive Migraine Treatments

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 the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.3 Provides clear and structured explanations about diagnosis, prognosis, and management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured headache history, including triggers, symptom pattern, and red flags.
2.2 Identifies signs and symptoms requiring further investigation for secondary causes of headache.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates migraine from other primary and secondary headaches.
3.2 Identifies when further investigations or specialist referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides an evidence-based acute and preventive treatment plan.
4.2 Educates the patient on lifestyle modifications and non-pharmacological management.

5. Preventive and Population Health

5.1 Identifies lifestyle and dietary triggers contributing to migraine.
5.2 Advises on long-term migraine prevention strategies.

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up of treatment effectiveness.

8. Procedural Skills

8.1 Assesses the need for imaging (CT or MRI) if red flag symptoms are present.

9. Managing Uncertainty

9.1 Recognises when a headache requires urgent referral for neurological assessment.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies severe or chronic migraine requiring escalation of treatment.

Competency at Fellowship Level

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