CASE INFORMATION

Case ID: CCE-2025-02
Case Name: Sarah Thompson
Age: 32
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: N01 (Headache), N89 (Migraine), N17 (Tension-type headache)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages with the patient empathetically. 1.2 Uses clear, patient-centred language to explore headache history. 1.4 Elicits patient’s ideas, concerns, and expectations.
2. Clinical Information Gathering and Interpretation	2.1 Takes a structured headache history, identifying red flags. 2.2 Identifies associated symptoms (e.g., nausea, photophobia, neurological signs). 2.3 Determines potential triggers (e.g., stress, diet, sleep disturbances).
3. Diagnosis, Decision-Making and Reasoning	3.1 Recognises primary vs. secondary headaches and formulates differentials. 3.3 Appropriately identifies red flag symptoms requiring urgent investigation.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a stepwise management plan based on diagnosis. 4.3 Provides pharmacological and non-pharmacological treatment. 4.5 Refers appropriately when indicated.
5. Preventive and Population Health	5.2 Provides lifestyle modifications to prevent headache recurrence.
6. Professionalism	6.1 Ensures empathetic and non-judgemental communication.
7. General Practice Systems and Regulatory Requirements	7.2 Understands appropriate use of imaging and referrals based on guidelines.
9. Managing Uncertainty	9.1 Recognises limitations in diagnosing headache subtypes and ensures safety-netting.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises serious headache causes (e.g., subarachnoid haemorrhage, meningitis, space-occupying lesion).

CASE FEATURES

Young female with recurrent headaches affecting daily life.
History-taking skills are critical to differentiate between primary and secondary headaches.
Risk assessment for serious pathology and appropriate investigation planning.
Stepwise management approach, including pharmacological and non-pharmacological strategies.
Preventive strategies for chronic headache sufferers.

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:

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

SCENARIO

Sarah Thompson, a 32-year-old accountant, presents to your general practice clinic complaining of frequent headaches over the past six months. She describes a dull, band-like pressure around her forehead that worsens throughout the day. The headache is bilateral, not associated with nausea or vomiting, and does not worsen with physical activity. However, she has had episodes of more intense headaches with throbbing pain, nausea, and photophobia that last for hours, during which she has to lie in a dark room.

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Thompson
Age: 32
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Ibuprofen PRN
Combined oral contraceptive pill

Past History

Nil significant

Social History

Works as an accountant, long hours on a computer
No smoking, minimal alcohol use

Family History

Mother has migraines
No family history of brain tumours or strokes

Smoking and Alcohol

Non-smoker
Drinks alcohol occasionally

Vaccination and Preventative Activities

Routine vaccinations up to date

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, I’ve been getting these headaches more often, and I’m really worried it could be something serious.”

General Information

You are Sarah Thompson, a 32-year-old accountant who has been experiencing frequent headaches for the past six months. These headaches have become more noticeable and disruptive, making it difficult for you to concentrate at work and enjoy your usual activities.

You describe two types of headaches:

A daily, dull, band-like pressure around your forehead that worsens throughout the day, especially when you’re stressed or after long hours at the computer.
Occasional severe headaches with throbbing pain, nausea, and sensitivity to light, lasting several hours and forcing you to lie down in a dark room. These occur once or twice a month.

Specific Information

(Revealed When Asked)

Background Information

You are worried that these headaches could be a sign of a brain tumour, especially since they have been occurring more frequently. You have searched online, and some of your symptoms match what you read about serious conditions. You haven’t had any medical tests yet, but you’ve been thinking about asking for a brain scan. You have no history of migraines, but your mother used to get them when she was younger.

You have been taking ibuprofen occasionally, but it only helps sometimes. You haven’t noticed any specific pattern with food, exercise, or weather changes, but you do drink 3–4 cups of coffee daily and sometimes skip meals when busy.

Your work as an accountant means you spend long hours staring at screens, and you often feel tense in your shoulders and neck. You sleep poorly, getting about 4–5 hours of sleep per night, and wake up feeling tired most days. You are generally healthy otherwise.

Headache Characteristics

Daily dull pressure headaches:
- Feels like a tight band around your head.
- Mild to moderate in severity, gets worse as the day progresses.
- Worse with stress, long screen time, and lack of sleep.
- No nausea, vomiting, or aura.
Occasional severe headaches (1–2 times per month):
- Throbbing pain, usually on one side of the head.
- Associated with nausea, photophobia, and phonophobia.
- Lasts for several hours, sometimes forcing you to rest in a dark room.
- Improves with sleep or lying down quietly.

Triggers and Risk Factors

Work-related stress, long hours at the computer.
Poor sleep (4–5 hours per night).
High caffeine intake (3–4 coffees per day).
Skipping meals occasionally.
No recent illness, fever, or neck stiffness.

Impact on Daily Life

Work performance has suffered due to difficulty concentrating.
You’ve cancelled social plans a few times due to severe headaches.
Your partner is worried because you complain about headaches almost daily.
You are anxious because your symptoms are getting more frequent and severe.

Emotional Cues and Body Language

Anxious and fidgety when discussing the possibility of a brain tumour.
Frustrated about the impact on work and daily life.
Skeptical but willing to listen when the doctor explains the cause.
Relieved if reassured about non-serious causes but will ask questions to confirm understanding.

Patient Concerns and Questions

“Do I need a brain scan?” – You are particularly worried about missing a serious condition.
“Why am I getting these headaches?” – You want a clear explanation.
“How can I stop them?” – You are open to lifestyle changes but prefer practical strategies.
“Are these migraines?” – You don’t fully understand the difference between migraine and other headaches.
“Will I need to take medication forever?” – You are not keen on long-term medication use.

Possible Reactions Based on the Doctor’s Approach

If the doctor reassures you and explains the diagnosis well:

You feel relieved and open to management strategies.
You may say something like, “That makes sense. So, it’s more about lifestyle changes?”

If the doctor dismisses your concerns or doesn’t take the headache history seriously:

You insist on getting a brain scan because you are worried about a tumour.
You might say, “But what if we’re missing something serious?”

If the doctor suggests a migraine diagnosis without explaining it clearly:

You feel uncertain and may ask, “But I thought migraines were only severe headaches? Do I have both types?”

If the doctor provides a clear plan with lifestyle changes and medication options:

You express interest in practical solutions like stress reduction and better sleep.
You ask follow-up questions about how to adjust caffeine intake and work habits.

Your Expectations from This Consultation

You want reassurance that this isn’t a serious medical issue like a tumour.
You want a clear explanation of why you are getting headaches.
You want practical strategies to help prevent headaches.
You are open to medication but prefer non-drug solutions first.
You need to feel heard—if the doctor brushes off your concerns, you may push for unnecessary investigations.

End of Consultation Cues

If the doctor gives practical advice, you nod and consider it.
If the doctor presses too hard on lifestyle changes without acknowledging your concerns, you might seem unconvinced.
If the doctor engages well, you might accept a follow-up appointment to reassess your headaches in a few weeks.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate headache history, including red flag symptoms and impact on daily life.

The competent candidate should:

Use open-ended questions to establish the headache pattern, severity, and associated symptoms.
Clarify headache characteristics, including:
- Onset (sudden vs. gradual).
- Location (unilateral, bilateral, occipital, frontal).
- Duration and frequency (episodic vs. chronic).
- Quality of pain (throbbing, pressure, stabbing).
- Associated symptoms (nausea, photophobia, phonophobia, visual aura, neurological deficits).
Screen for red flag symptoms that may indicate serious pathology:
- Sudden onset “thunderclap” headache.
- Neurological signs (weakness, altered sensation, visual changes, speech difficulties).
- Fever, neck stiffness, or recent trauma.
- Progressively worsening headache.
- Headache triggered by exertion, coughing, or positional changes.
Assess impact on daily life, including work, sleep, and social activities.
Explore lifestyle factors (stress, caffeine intake, sleep patterns, screen time).
Take a relevant medical and family history, including personal or family history of migraine, hypertension, or other neurological conditions.

Task 2: Formulate a differential diagnosis, including primary and secondary headache causes.

The competent candidate should:

Distinguish between primary and secondary headaches:
- Primary headaches:
  - Tension-type headache (bilateral, pressure-like, stress-related).
  - Migraine (unilateral, throbbing, photophobia, nausea, disabling).
  - Cluster headache (severe unilateral pain, autonomic symptoms).
- Secondary headaches (potentially serious underlying causes):
  - Subarachnoid haemorrhage (sudden onset, worst-ever headache, meningism).
  - Meningitis (fever, neck stiffness, altered consciousness).
  - Brain tumour (persistent headache, morning worsening, neurological signs).
  - Giant cell arteritis (age >50, scalp tenderness, jaw claudication, visual disturbance).
  - Medication-overuse headache (daily headache with analgesic overuse).
Determine likelihood of a serious cause by correlating symptoms with risk factors.

Task 3: Explain the likely diagnosis to the patient in a clear and patient-centred manner.

The competent candidate should:

Provide reassurance that based on the history, a serious cause is unlikely.
Explain the most likely diagnosis in lay terms:
- “Your symptoms are most consistent with tension-type headaches due to stress and prolonged screen time. You also have features of migraine during some episodes.”
Address the patient’s concerns about a brain tumour:
- “Brain tumours usually cause persistent, progressive headaches with neurological symptoms. Your headaches do not follow this pattern.”
Discuss when further investigation is needed (e.g., if symptoms change or red flags develop).
Ensure patient understanding by using teach-back techniques.

Task 4: Develop a safe and effective management plan, including symptom relief and preventive strategies.

The competent candidate should:

Acute management:
- Tension headaches: Simple analgesia (paracetamol, ibuprofen), stress reduction.
- Migraines: First-line (NSAIDs, triptans if severe), hydration, rest in a quiet, dark room.
Non-pharmacological strategies:
- Improve sleep hygiene (regular bedtime, screen reduction).
- Reduce caffeine intake gradually.
- Encourage stress management (exercise, relaxation techniques).
Preventive strategies for frequent migraines:
- Identify triggers (diet, dehydration, hormonal factors).
- Consider prophylactic medications (e.g., propranolol, amitriptyline) if frequent and disabling.
Discuss safety-netting:
- Follow up if symptoms worsen or change.
- Seek urgent care if sudden severe headache, vision loss, neurological changes occur.

SUMMARY OF A COMPETENT ANSWER

Elicits a structured headache history, screening for red flags.
Considers primary and secondary headache causes, distinguishing benign from serious conditions.
Provides a clear, patient-centred explanation of the likely diagnosis.
Addresses the patient’s concerns about a brain tumour, providing reassurance with evidence.
Develops a stepwise management plan, including lifestyle modifications and pharmacological options.
Ensures safety-netting, advising the patient on when to seek further care.

PITFALLS

Failing to ask about red flag symptoms, missing a potentially serious diagnosis.
Overlooking lifestyle factors, such as poor sleep, stress, and caffeine intake.
Assuming all headaches are migraines without considering other primary or secondary causes.
Not addressing the patient’s fears about a brain tumour, leading to persistent anxiety.
Over-reliance on imaging when not clinically indicated, leading to unnecessary investigations.
Failing to discuss preventive strategies, leading to continued headache recurrence.

REFERENCES

MARKING

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

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

Competency Areas Assessed

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, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive headache history, identifying red flags.
2.2 Identifies associated symptoms and triggers.
2.3 Determines potential serious underlying causes.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises primary vs. secondary headaches and formulates differentials.
3.3 Identifies red flag symptoms requiring urgent investigation.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a stepwise management plan.
4.3 Provides pharmacological and non-pharmacological treatment.
4.5 Refers appropriately when indicated.

5. Preventive and Population Health

5.2 Provides lifestyle modifications for headache prevention.

6. Professionalism

6.1 Ensures empathetic and non-judgemental communication.

7. General Practice Systems and Regulatory Requirements

7.2 Understands appropriate use of imaging and referrals.

9. Managing Uncertainty

9.1 Recognises limitations in diagnosing headache subtypes and ensures safety-netting.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises serious headache causes requiring escalation.

Competency at Fellowship Level

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