CCE-CE-183

CASE INFORMATION

Case ID: TH-001
Case Name: John Matthews
Age: 42
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: N89 (Tension-type headache)​

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to understand their concerns and expectations
1.2 Explains diagnosis and management clearly
1.5 Uses active listening skills and empathy
2. Clinical Information Gathering and Interpretation2.1 Conducts an appropriate history to explore headache characteristics, triggers, and red flags
2.2 Identifies risk factors and contributing factors
3. Diagnosis, Decision-Making and Reasoning3.1 Forms an appropriate differential diagnosis
3.2 Identifies features suggestive of serious secondary causes requiring escalation
4. Clinical Management and Therapeutic Reasoning4.2 Develops a management plan including pharmacological and non-pharmacological strategies
4.3 Provides lifestyle modification advice to reduce recurrence
5. Preventive and Population Health5.1 Identifies and addresses lifestyle factors contributing to tension headaches
5.3 Provides advice on stress management and posture correction
6. Professionalism6.2 Maintains patient confidentiality and establishes a therapeutic relationship
7. General Practice Systems and Regulatory Requirements7.3 Provides appropriate documentation and safety netting advice
9. Managing Uncertainty9.1 Recognises when further investigations are required for atypical headache features
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies red flag features that suggest serious underlying pathology

CASE FEATURES

  • Middle-aged male presenting with chronic headaches
  • Symptoms suggestive of tension-type headache
  • Need to rule out red flag features of secondary headache
  • Patient concerns about a serious underlying condition (e.g., brain tumour)
  • Discussion around pharmacological vs. non-pharmacological management
  • Stress and posture-related contributing factors
  • Need for reassurance, education, and lifestyle modifications

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:

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

SCENARIO

John Matthews, a 42-year-old office worker, presents with a history of headaches for the past six months. He describes the pain as a band-like tightness around his forehead and the back of his head. The headaches occur 3-4 times per week, often in the late afternoon. They last for several hours but are not associated with nausea, vomiting, visual changes, or neurological deficits.

PATIENT RECORD SUMMARY

Patient Details

  • Name: John Matthews
  • Age: 42
  • Gender: Male
  • Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Paracetamol (as needed)
  • Ibuprofen (as needed)

Past History

  • No significant medical history

Social History

  • Works as an IT professional, long hours at a desk

Family History

  • No family history of neurological disorders

Smoking

  • Non-smoker

Alcohol

  • Drinks 1-2 standard drinks per week

Vaccination and Preventative Activities

  • Up to date with vaccinations

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

“Hi, doctor. I’ve been getting these headaches for months now, and I’m starting to worry it’s something serious, like a brain tumour.”

General Information

(Freely Shared if Asked Open-Ended Questions)

  • The headaches started about six months ago and seem to be happening three to four times a week.
  • The pain is a dull, tight, band-like pressure that wraps around the forehead and back of the head.
  • The headaches often start in the afternoon while working and can last for a few hours, sometimes into the evening.
  • The pain is usually mild to moderate, around 4-5/10 in severity, but it can be annoying and distracting.

Specific Information

(Only If the Candidate Asks Targeted Questions)

Background Information

  • There is no nausea, vomiting, or vision problems, and no sensitivity to light or noise.
  • He has been using paracetamol and ibuprofen, which provide some relief, but the headaches keep coming back.
  • He has not had any head injuries or concussions.
  • He has a high-stress job as an IT professional, working long hours at a desk with poor posture.
  • He often clenches his jaw when focusing on work or during stressful moments.

Headache Characteristics

  • The headaches feel like a tight band squeezing the head rather than a throbbing or sharp pain.
  • The pain does not worsen with physical activity.
  • He sometimes notices the headaches more on workdays and less on weekends.
  • He has noticed that he rubs his temples and neck often during work.

Lifestyle Factors & Triggers

  • He spends 8-10 hours a day in front of a computer, often leaning forward and hunching over.
  • He does not take regular breaks while working.
  • He sleeps about 6 hours a night, often thinking about work problems before bed.
  • He does not exercise regularly and mostly sits during the day.
  • He drinks coffee (1-2 cups per day) but no energy drinks or soft drinks.
  • He does not smoke and drinks 1-2 alcoholic drinks per week.
  • He has never had migraines before.

Psychosocial Context

  • He worries a lot about his health and recently read an article about brain tumours, which has made him anxious.
  • His job is high-pressure, and he often has deadlines and long hours.
  • He is married and has two young children but feels like he is not spending enough time with them due to work stress.
  • His wife has told him to see a doctor because he keeps talking about his headaches and worrying about the worst-case scenario.

Treatment History

  • He takes paracetamol (Panadol) or ibuprofen (Nurofen) as needed, which help a little but don’t stop the headaches from returning.
  • He has not tried any other treatments like physiotherapy, massage, relaxation techniques, or posture changes.
  • He has not had any recent medical check-ups or blood tests.

Emotional Cues & Reactions

  • Worried and anxious about a serious condition, especially a brain tumour.
  • Relieved if the doctor provides a logical explanation for the headaches.
  • Frustrated that the headaches keep happening despite taking painkillers.
  • Skeptical about non-medication treatments at first but open to trying if explained well.
  • Reassured if the doctor listens carefully, takes his concerns seriously, and provides a clear management plan.

Questions the Patient Might Ask

  1. Could this be a brain tumour? – (If not reassured, he might press further, saying: “But how do you know for sure? Don’t I need a scan?”)
  2. What else could be causing these headaches?
  3. Should I be taking painkillers every day? Is that safe?
  4. What can I do to stop these headaches from coming back?
  5. Would a scan or blood test help figure out what’s going on?
  6. Do I need to see a specialist, like a neurologist?

How to Play the Role

  • At the beginning, sound worried and frustrated, especially when mentioning that the headaches have been going on for months.
  • When discussing work stress, sound stressed but not overly dramatic—like someone just getting on with it but feeling the strain.
  • When the doctor reassures you that it’s likely tension-type headaches, look relieved but still slightly skeptical—you might ask “So how can we be sure?”
  • If the doctor suggests lifestyle changes, respond with hesitation at first (e.g., “I don’t know if I have time for that…”) but gradually open up if the explanations make sense.
  • If the doctor explains red flag symptoms to watch for, listen carefully and nod in understanding.

Final Reactions Based on the Doctor’s Approach

  1. If the doctor explains things well and reassures you:
    • You feel relieved and say something like “That makes sense, I hadn’t thought about my posture and stress causing this.”
    • You agree to try some non-medication approaches, like taking breaks, stretching, and stress management.
  2. If the doctor rushes through or dismisses your concerns:
    • You feel frustrated and unconvinced. You might say: “But what if it is something more serious? I’d feel better with a scan.”
  3. If the doctor only suggests painkillers without addressing lifestyle factors:
    • You respond with concern: “I don’t want to rely on painkillers forever. Is there anything else I can do?”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient, including headache characteristics and lifestyle factors.

The competent candidate should:

  • Use open-ended questions to allow the patient to describe the headaches in their own words.
  • Explore headache characteristics, including onset, duration, location, intensity, quality, associated symptoms, aggravating and relieving factors.
  • Clarify red flag symptoms, such as sudden onset, worsening over time, neurological symptoms, fever, or recent head trauma.
  • Assess lifestyle factors, including work-related stress, screen time, posture, jaw clenching, sleep habits, exercise, caffeine intake, and hydration.
  • Explore psychosocial factors, including work stress, anxiety about serious illness, family history, and personal coping strategies.
  • Summarise findings to confirm understanding and check for patient concerns and expectations.

Task 2: Discuss your differential diagnosis and explain the most likely cause of the headaches.

The competent candidate should:

  • Provide a structured differential diagnosis using a primary, secondary, and serious causes approach.
  • Explain that tension-type headache (TTH) is the most likely diagnosis, given the bilateral, band-like tightness, lack of nausea/vomiting, no photophobia, and association with stress and poor posture.
  • Exclude serious causes such as subarachnoid haemorrhage, brain tumour, or meningitis, by clarifying the absence of red flag symptoms.
  • Mention other potential differentials, including migraine (unlikely due to lack of aura, nausea, or throbbing quality) and medication overuse headache (given frequent use of painkillers, but symptoms not worsening over time).
  • Reassure the patient while addressing his concern about a brain tumour, explaining why his symptoms do not match a concerning neurological pattern.

Task 3: Address the patient’s concerns and provide education on red flag symptoms.

The competent candidate should:

  • Acknowledge and validate the patient’s anxiety about a serious cause, particularly a brain tumour.
  • Use empathetic, patient-centred communication to explain why his headaches are most likely benign.
  • Outline red flag symptoms that would warrant further investigation, such as:
    • New or worsening headaches in a patient over 50 years old.
    • Sudden onset ‘thunderclap’ headache.
    • Headache associated with neurological signs (weakness, vision changes, speech issues).
    • Headache with fever, neck stiffness, or recent trauma.
  • Reassure the patient that no immediate imaging is required but he should return if symptoms change.

Task 4: Develop a patient-centred management plan, including pharmacological and non-pharmacological strategies.

The competent candidate should:

  • Provide a multifaceted management approach focusing on lifestyle changes, stress management, and symptomatic relief.
  • Recommend non-pharmacological measures:
    • Posture correction at work (adjusting desk setup, ergonomic chair, frequent breaks).
    • Jaw relaxation exercises to reduce clenching.
    • Stress reduction techniques such as deep breathing, mindfulness, and regular exercise.
    • Sleep hygiene advice to improve sleep patterns.
  • Limit analgesic use to prevent medication overuse headache (paracetamol/ibuprofen max 2-3 times per week).
  • Consider physiotherapy if neck tension is a major factor.
  • Offer follow-up in 2-4 weeks to reassess symptoms and reinforce strategies.

SUMMARY OF A COMPETENT ANSWER

  • Comprehensive history-taking, covering headache characteristics, triggers, lifestyle, and red flags.
  • Structured differential diagnosis, with clear exclusion of serious pathology.
  • Empathetic and patient-centred communication, addressing the patient’s concerns about serious illness.
  • Clear explanation of red flag symptoms, ensuring the patient understands when to seek urgent care.
  • Holistic management approach, including lifestyle modifications, stress management, and responsible medication use.
  • Appropriate safety netting, advising follow-up if symptoms persist or change.

PITFALLS

  • Failing to explore red flag symptoms – missing serious conditions like intracranial haemorrhage or space-occupying lesions.
  • Over-reliance on imaging – ordering unnecessary brain scans without clinical indications.
  • Dismissive communication – not adequately addressing the patient’s anxiety about a brain tumour.
  • Neglecting lifestyle factors – overlooking posture, stress, or jaw clenching as triggers.
  • Inappropriate medication advice – not cautioning against overuse of analgesics.
  • Lack of safety netting – failing to provide follow-up advice or warning signs to watch for.

REFERENCES

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.
1.5 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Conducts an appropriate history to explore headache characteristics, triggers, and red flags.
2.2 Identifies risk factors and contributing factors.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms an appropriate differential diagnosis.
3.2 Identifies features suggestive of serious secondary causes requiring escalation.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops a management plan including pharmacological and non-pharmacological strategies.
4.3 Provides lifestyle modification advice to reduce recurrence.

5. Preventive and Population Health

5.1 Identifies and addresses lifestyle factors contributing to tension headaches.
5.3 Provides advice on stress management and posture correction.

6. Professionalism

6.2 Maintains patient confidentiality and establishes a therapeutic relationship.

7. General Practice Systems and Regulatory Requirements

7.3 Provides appropriate documentation and safety netting advice.

9. Managing Uncertainty

9.1 Recognises when further investigations are required for atypical headache features.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies red flag features that suggest serious underlying pathology.

Competency at Fellowship Level

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