SIMULATED PATIENT (ROLE-PLAYER) BRIEF

Persona. You are Aisha Begum, 32, a Year 3 primary school teacher of British-Bangladeshi background. Articulate, polite, slightly tense at first. On video, sitting at your kitchen table; tired but well-looking; NOT in pain right now. Eye contact good initially; look down when your aunt comes up — there may be a small voice-wobble, but you don’t cry. You warm up if listened to; if rushed you go quieter and more guarded.

Opening line (verbatim). “Hi doctor, thanks for fitting me in. I keep getting these horrible headaches — they’ve been coming for months now, and I just want to know what’s going on.”

History to give IF ASKED

Presenting complaint

• Started about 6 months ago. Thought it was work stress.
• 2–3 attacks a month. Often Saturdays — your husband thinks it’s because you don’t drink water at school and “crash” at weekends.
• One-sided: usually right, sometimes left, only ever one side at a time.
• Throbbing, “like a heartbeat in my head”. 8/10 at peak.
• Each lasts most of the day, about 12 hours. Builds over an hour, worst for a few hours, then eases.
• Nausea every time. Vomited twice.
• Bright light bothers you a lot — curtains drawn, lie in the dark. Sound also bothers you.
• Walking and climbing stairs makes it worse.
• You take 2 paracetamol and 2 ibuprofen from the cupboard. Helps if taken early; doesn’t touch it if late. Only on headache days — NOT taking painkillers every day.

Relevant negatives (confirm if asked) — ALL red flags ABSENT

• No flashing lights, zig-zags, blind spots, or any visual disturbance before or during.
• No tingling, numbness, weakness, speech difficulty.
• No fever, neck stiffness, rash.
• No loss of consciousness, no fits.
• No thunderclap onset — they build over an hour.
• No headache worse when bending, coughing, sneezing or lying flat.
• No recent head injury.
• No change in personality or memory (husband hasn’t noticed anything).
• No weight loss, no night sweats.

Background

• Otherwise well. No regular medication. No allergies.
• Periods regular. No link to headaches that you’ve noticed.
• Contraception: not currently using any. You and your husband are “starting to think about” trying for a baby in the next year — mention only if asked about contraception, sex life or pregnancy plans.
• Mother had migraines as a young woman, improved after menopause — mention only if asked about family history of headaches.

Lifestyle. Non-smoker; 1–2 units alcohol/week; three mugs of tea daily on weekdays, none at weekends (only mention this drop if asked); 7 hours sleep weekdays, long lie-in at weekends (only if asked about sleep); skip breakfast in the school rush; little water during the school day; little exercise; school year tough with Year 3 SATs (Standard Assessment Tests) coming up.

ICE (Ideas, Concerns and Expectations)

• Idea — you half-suspect migraine because your mum had them. Verbatim if asked: “I think it might be migraines — my mum used to get them. But the thing is, they keep coming and they’re getting in the way of everything.”
• Concern — you are afraid it might be a brain tumour because your aunt (your mum’s sister) died of one in her early forties.
• Expectation — you came in wanting to know what’s causing it. Underneath: you hope for a scan or specialist referral so you can stop worrying. Verbatim: “I just want to know what’s causing it. I suppose I was wondering if I should have a scan — just to rule things out.”

Hidden agenda — reveal rule (mandatory)

The brain-tumour fear is moderately hidden. You do NOT lead with it.

Reveal the aunt and the cancer fear ONLY IF the candidate either (a) asks an open question about what you are most worried about or what’s on your mind, OR (b) picks up a visible cue and names it (“You seem a little upset — what’s going through your mind?”).

If neither happens by minute 7, drop the cue line: “My auntie had headaches like this and… well, they turned out to be something serious.” If still not followed up, say more explicitly when management is offered: “But how can you be sure it’s not something more serious without a scan?”

Do NOT reveal the aunt unprompted in the first 3 minutes.

Cues to drop

• Pause and look down when family history is asked.
• “It’s just… I worry about what it could be.”
• “I should have come in sooner, really, but I was scared.”

Response to a GOOD vs POOR consultation

• GOOD (open questions, picks up the cue, names the fear about your aunt, takes time with the scan question): shoulders drop on camera, “OK, that makes sense”, you engage with the plan, agree to medication and diary.
• POOR (closed checklist, talks over you, dismisses scan with “you don’t need one”): you stay quiet, face shows you’re not convinced, “I suppose, but I’m still worried it might be something more serious.” You won’t push back angrily — but you won’t feel reassured.

Findings the actor can provide if asked (REMOTE-CONSULTATION CONSTRAINTS)

• Visible on camera: well, tired but not unwell. Alert. Sitting comfortably. Not pale, not sweating. No facial droop. Speech clear and fluent. If asked to smile, raise arms, stick tongue out, follow a finger with eyes, or walk a few steps — all normal and symmetrical.
• Audible: clear speech, no slurring, no breathlessness, no cough.
• At home you have: thermometer, bathroom scales. You do NOT have a BP machine, pulse oximeter or glucometer.
• Self-measured if asked: temperature 36.7 °C; weight ~62 kg. Cannot measure own BP at home.
• For anything else (auscultation, fundoscopy, otoscopy, reflexes, palpation): “I can’t really do that myself — sorry.”

Response to a face-to-face offer

Classification: OVER-CAUTIOUS. Face-to-face is NOT clinically indicated; the competent candidate concludes remotely with a safety-net.

• Realistic obstacle if face-to-face is offered: “Do I really need to come in? I’m back at school tomorrow and we have a parents’ evening Thursday — it’s such a busy week. Is it really necessary?”
• Trigger to AGREE: you only agree if given a specific clinical reason (e.g. “I’d want to check your BP” or “look in the back of your eyes”). If the offer is vague (“just to be safe”) you remain reluctant and are NOT reassured.
• If pressed without a reason: “If you really think I need to, but honestly, can we not just sort this out today?”
• If you do agree: “OK, if you think it’s important to check that, I’ll come in. When can you fit me in?”

Questions you might ask the doctor

• “Could this be a brain tumour?”
• “Don’t you think I should have a scan, just to be sure?”
• “Will this medication make me drowsy? I’m driving to school.”
• “Is it safe to keep taking the painkillers I’ve been taking?”
• “My mum had migraines — will mine get better with age too?”

Actor latitude

LOCKED (must not vary):

• All clinical facts: 6-month timeline, unilateral throbbing 8/10 headaches lasting ~12 hours with nausea and photophobia, 2–3 attacks per month, no aura, ALL red flags absent.
• Family history: maternal aunt died of brain tumour aged 43; mother had migraines.
• Hidden-agenda content (brain-tumour fear) AND its reveal trigger (open question OR cue-naming).
• ICE positions (idea = migraine; concern = brain tumour; expectation = scan/specialist).
• Face-to-face classification (OVER-CAUTIOUS) and the rule that you only agree if given a specific clinical reason.
• Verbatim opening line.

FLEXIBLE (vary to sound human):

• Exact wording of replies to closed questions.
• Order in which secondary details (sleep, caffeine, hydration, stress) come out.
• Specific words used to push back on vague offers.
• Small character-consistent details (which class she teaches, husband’s name) — keep consistent within a single run.
• Emotional intensity when speaking about your aunt (voice-wobble to brief tearful eyes — not full crying).

Tone: be a real, articulate patient who has been quietly frightened for months. The locked facts protect the clinical test; the flexibility keeps you human.

PART A – EXAMINER MARKING GUIDE

Clinical-management archetype with a moderately hidden agenda. Roughly equal weight across the three domains; Clinical Management is the centre of gravity, with Relating to Others a close second.

1) Data Gathering & Diagnosis

Positive indicators

• Opens with an open question and tolerates 30–60 seconds of patient narrative without interrupting.
• Maps history onto International Classification of Headache Disorders, 3rd edition (ICHD-3) criteria for migraine without aura: unilateral, throbbing, moderate–severe, aggravated by routine activity, plus nausea/vomiting, photophobia, phonophobia, duration 4–72 hours.
• Runs a structured red-flag sweep — thunderclap onset; focal neurology (weakness, numbness, speech, vision, balance); fever, neck stiffness, rash; head trauma; Valsalva/exertional/postural triggers; change in pattern; immunocompromise — signposted, not rattled.
• Asks specifically about aura (visual zig-zags/scotoma, sensory, dysphasia) and confirms absence.
• Picks up the brain-tumour cue within the first 7 minutes by an open ICE (Ideas, Concerns and Expectations) question OR cue-naming.
• Quantifies over-the-counter analgesia use to screen for emerging medication-overuse headache (MOH).
• Summarises back to the patient before management.

Negative indicators

• Closed checklist from minute one; interrupts within 20 seconds.
• Anchors on “migraine” before completing the red-flag screen.
• Omits a major red-flag category (thunderclap, focal neurology, Valsalva, change in pattern).
• Aura not asked.
• Misses the aunt/brain-tumour cue.
• No quantification of analgesia use.

Calibration anchor

• Clear Pass: Opens open, lets her speak 30–60 seconds. Signposts the red-flag screen as a structured sweep. ICHD-3 features asked systematically. Aura specifically excluded. Surfaces the brain-tumour fear spontaneously by minute 6 from a cue or open ICE.
• Pass: Open question used but interrupts within 20 seconds. Red-flag screen completed but checklist-like. Aura asked. Brain-tumour fear surfaces after a direct ICE question.
• Fail: Closed throughout. Red-flag screen incomplete (e.g. omits thunderclap OR Valsalva OR change in pattern). Aura not asked. Brain-tumour fear missed.
• Clear Fail: No structured history. Anchors prematurely on “stress headaches”. Multiple red flags omitted. ICE never elicited.

2) Clinical Management & Medical Complexity

Positive indicators

• Makes a positive diagnosis of episodic migraine without aura and states it explicitly.
• Explains no scan is needed because the diagnosis is made from the pattern and no red flags are present (consistent with National Institute for Health and Care Excellence (NICE) NG150 — neuroimaging is not used to provide reassurance alone). Frames as a clinical positive, not a refusal.
• Offers stepwise acute treatment with shared decision-making and exact doses: sumatriptan 50 mg PO at headache onset, plus ibuprofen 400 mg PO at the same time (NICE-recommended combination), or simple analgesia alone first if she prefers a lighter step.
• Gives the sumatriptan warning near-verbatim: “If you feel any chest, throat or jaw tightness or heaviness, stop the sumatriptan and ring us.”
• If offering an antiemetic, chooses prochlorperazine 10 mg PO for this patient OR explicitly flags the Medicines and Healthcare products Regulatory Agency (MHRA) 2013 advice that metoclopramide causes acute dystonic reactions more commonly in young women, restricted to 5 days, 10 mg up to three times daily.
• MOH counselling: ≤2 days per week of acute treatment; explains the 15+/10+ days-per-month thresholds.
• Headache diary for at least 8 weeks.
• Lifestyle counselling targeted to her triggers: regular meals, hydration through the school day, consistent sleep across weekdays/weekends, caffeine consistency, stress.
• Arranges follow-up at 2–8 weeks (in line with NICE and Clinical Knowledge Summaries (CKS)).
• Safety-net keyed to red flags (see below).

Negative indicators

• Vague management (“take painkillers and see how you go”).
• Wrong doses (e.g. sumatriptan 25 mg first-line; ibuprofen 200 mg).
• Prescribes metoclopramide in a 32-year-old woman without flagging the dystonia risk.
• Offers codeine, co-codamol, tramadol, any opioid.
• No MOH counselling; no headache diary.
• Refers for brain MRI (magnetic resonance imaging) or CT (computed tomography) “just to be sure”.
• Refers to neurology with no clinical indication.
• Inappropriately insists on face-to-face without a stated clinical reason.
• Safety-net consists only of “come back if it gets worse”.

Calibration anchor

• Clear Pass: Diagnosis explicit. Offers combination (sumatriptan 50 mg + ibuprofen 400 mg at onset) AND the simple-analgesia option, framed as shared decision-making. Chest-tightness warning given. Antiemetic either deferred or prochlorperazine chosen with the metoclopramide MHRA caveat. MOH message specific (≤2 days/week). Diary 8 weeks. Lifestyle tied to her triggers. Safety-net lists named symptoms. Concludes remotely with no unnecessary scan, referral or face-to-face.
• Pass: Diagnosis made. Sumatriptan 50 mg correctly prescribed. Key warning given. MOH mentioned. Diary suggested. Safety-net present. May choose metoclopramide without flagging MHRA but at the correct dose.
• Fail: Vague prescribing or missing key warnings. No MOH. No diary. Generic safety-net. OR scan/specialist offered with no clinical justification. OR unnecessary face-to-face escalation.
• Clear Fail: No coherent plan. Wrong doses. Opioid offered. Brain scan ordered to reassure. Multiple safety errors.

Face-to-face decision: OVER-CAUTIOUS. Not clinically indicated; no examination would change management. Conclude remotely with a robust safety-net.

• Positive: concludes remotely with an explicit safety-net listing named red-flag symptoms and a timeframe.
• Negative: insists on face-to-face without a stated clinical reason, OR concludes remotely with no specific safety-net.

3) Relating to Others

Positive indicators

• Names and acknowledges the emotional layer before management: “It sounds like watching what happened to your aunt has been on your mind — that must be frightening.”
• Validates the brain-tumour concern as understandable BEFORE explaining why a scan is not the right next step.
• Plain English throughout — no jargon to the patient.
• Shares the decision on treatment: “There are a couple of ways we could approach this — would you like me to talk you through them?”
• Checks understanding at the end (teach-back or clear summary the patient confirms).
• Tolerates silence after the brain-tumour topic is named.
• Closes with an explicit invitation to come back.

Negative indicators

• Dismisses the fear (“Don’t worry, it’s not a tumour”) without exploring it.
• Refuses a scan without first acknowledging why she asked.
• Jargon-heavy.
• Talks over the patient or fails to leave silence when she becomes tearful.
• Generic reassurance instead of specific explanation.
• No check of understanding.

Calibration anchor

• Clear Pass: Names the aunt and the brain-tumour fear explicitly and validates it before explaining the diagnosis. Plain English. Explicit treatment options offered, preference elicited. Pauses for silence. Patient visibly relaxes on camera. Closes with a warm, specific invitation to return.
• Pass: Acknowledges the worry, addresses the scan question without dismissing, plain English, checks understanding. Patient accepts the plan but the emotional layer is briefly held.
• Fail: Brain-tumour fear addressed only at the patient’s prompting and shut down quickly. Reassurance generic. Patient agrees flatly.
• Clear Fail: Dismisses the fear. Jargon-heavy. Patient ends visibly unreassured. No checking.

Working diagnosis: Episodic migraine without aura (ICHD-3 criteria met). Differentials excluded by history: tension-type headache (unilateral throbbing severe with nausea and photophobia argue against); MOH (current usage doesn’t meet criteria but is a future risk); cluster (duration and absence of autonomic features); secondary headache (no red flags). Must not miss: the structured red-flag screen in a new headache presentation.

Clear Pass discriminator. Clear Pass candidates name the aunt (“your mum’s sister — the one who had the brain tumour”) and acknowledge the fear by name BEFORE they explain why no scan is needed. Pass candidates explain why no scan is needed and the patient accepts it; Clear Pass candidates make her feel heard first, then explain — in that order.

PART B – MODEL CONSULTATION & MANAGEMENT

Timing target: agenda and history by minute 6; explanation and ICE by minute 8; management, safety-net and close by minute 12.

B1. Explain the condition

“From what you’ve described, this fits very well with migraine. A migraine is a particular kind of headache where the brain becomes briefly oversensitive to pain, to light, to sound, and to movement. It’s one-sided, throbbing, lasts most of a day, makes you feel sick, and light and noise make it worse – all classic migraine features. Migraine is very common, about one in seven people and often runs in families, which fits with your mum. Does that make sense so far?”

Pause. Check she follows.

B2. Respond to ICE

Idea: “You wondered whether it might be migraine, I think you’re right.”

Concern, naming the aunt: “You mentioned your auntie, your mum’s sister and what happened to her. I can completely understand why headaches like this have been frightening you. Can I tell you what I’ve been listening for, and why I’m not worried about that for you?”

“Brain tumours and other serious causes usually look quite different from migraine, typically a steady, persistent headache that gets worse over days to weeks, often worse when you cough, sneeze, bend or lie flat, and they usually come with other signs like new weakness, vision changes, a fit, or a change in alertness or personality that people around you might notice. None of that is happening with you. Your headaches come and go in clear attacks, fit a recognisable migraine pattern, and you’ve been completely well between them for six months. A scan in someone with this picture wouldn’t help, guidelines actually advise against doing one just for reassurance, because it can throw up incidental findings that lead to more worry, not less. What I’d like to do is treat the migraines and review you and I’ll be very clear about what to look out for in case anything changes.”

Expectation: “I know you came in hoping for a scan or specialist referral, so I want to be honest that I’m not doing that today, and explain why. But I am taking this seriously and we’ll review how you’re getting on.”

B3. Management plan

1. a) Shared decision-making framing

“There are two reasonable ways to start. One is to keep using paracetamol or ibuprofen but at proper migraine doses, and add in a specific migraine medicine called a triptan if that’s not enough. The other is to combine them at the start of each attack, which is what national guidelines recommend. Which would you rather try first?”

1. b) Lifestyle / non-drug

• Headache diary for at least 8 weeks (free from BASH — British Association for the Study of Headache): date, time, duration, severity, drugs taken and response, possible triggers.
• Triggers specific to her: skipping breakfast, low fluid intake at school, weekend caffeine drop, weekend lie-ins, work stress.
• Anchors: regular meals; water through the day at school; consistent sleep and caffeine across weekdays and weekends; some regular gentle exercise.

1. c) Medication — what to say to the patient

“At the very first sign of a headache not when it’s already bad, take sumatriptan 50 mg and ibuprofen 400 mg together with water. The earlier, the better they work. If it hasn’t really helped after two hours, don’t take a second sumatriptan for the same attack, but if you have another migraine on another day, use the same combination again.”

“One warning about sumatriptan: if you ever feel any tightness or heaviness in your chest, throat or jaw, stop it and ring us, that’s rare but important.”

“Don’t use these too often. If you’re needing painkillers more than two days a week regularly, please come back, using them too much can actually start to cause its own kind of headache.”

“If the nausea is a real problem, I can prescribe a few tablets of prochlorperazine to take alongside, but let’s see how you get on, many people find the sumatriptan settles the nausea too.”

1. c) Medication — prescription detail

Drug	Dose, formulation, route	Frequency / duration	How to take	Key warnings & cautions for THIS patient
Sumatriptan	50 mg PO (oral tablet); may step to 100 mg if 50 mg consistently insufficient on subsequent attacks	One dose at headache onset. If migraine recurs after responding, may repeat after at least 2 hours. Maximum 300 mg in 24 hours. Do NOT take a second dose for the same attack if the first has not worked.	At the start of the headache itself (she has no aura). Swallow with water.	Stop and seek advice if any tightness or heaviness in chest, throat or jaw. No contraindications for this patient (no ischaemic heart disease, no previous transient ischaemic attack (TIA) or stroke, no uncontrolled hypertension, not on a monoamine oxidase inhibitor or ergotamine, no severe hepatic impairment). May cause drowsiness — be cautious driving. No interacting medications on record.
Ibuprofen	400 mg PO (oral tablet)	One dose at headache onset, alongside sumatriptan. May repeat with subsequent attacks.	Swallow with water at the start of the headache.	No non-steroidal anti-inflammatory drug (NSAID) contraindication on her record (no asthma, no peptic ulcer, no renal impairment, not pregnant). Review needed if she becomes pregnant — MHRA advises avoiding NSAIDs after 20 weeks of pregnancy.
Prochlorperazine (if antiemetic preferred — short course only)	10 mg PO (oral tablet)	One dose with the acute attack if nausea is troublesome. Short-term only.	Take alongside sumatriptan and ibuprofen at onset.	Causes drowsiness — do not drive after taking. Occasional use only. Metoclopramide is the alternative (10 mg PO as a single dose at headache onset); per MHRA / Commission on Human Medicines (CHM) advice (August 2013), repeated use is restricted to 5 days at 10 mg up to three times daily, and acute dystonic reactions are more common in young women — prochlorperazine preferred here.

Explicitly NOT prescribed

• Codeine, co-codamol, dihydrocodeine, tramadol, any opioid — worsen migraine via MOH; advised against in headache management.
• Ergotamine / dihydroergotamine.
• Brain MRI or CT / neurology referral — not indicated; positive diagnosis from history; no red flags.

Suggested combination for this patient. At the start of each migraine, sumatriptan 50 mg PO + ibuprofen 400 mg PO together, with prochlorperazine 10 mg PO available if nausea is troublesome — no more than 2 days per week of acute treatment in total.

1. d) Follow-up. Review in 4–6 weeks (within the 2–8 week window), phone or video, to review the diary, efficacy, side effects and triggers. Sooner if she’s not coping.
2. e) Safety-net (verbatim)

“Ring 999 or go to A&E the same day if you ever have: a headache that comes on suddenly like a clap of thunder, reaching its peak within a few minutes; a headache with a fever, stiff neck, or a rash that doesn’t fade under pressure; weakness, numbness, or trouble speaking or seeing; a fit; or any change in how alert you feel.”

“Ring the surgery if your headaches change in any clear way — much more often, much worse, a different kind of pain than today, or much worse when you bend, cough, sneeze or lie flat — or if the medication isn’t working after a few attacks.”

“I’ll text you a link to a headache diary and a patient leaflet from The Migraine Trust.”

1. f) Health promotion

• Pre-conception: she plans a family in the next year. Note in record. Review medication before conception or as soon as she conceives — sumatriptan and ibuprofen are not first choices in pregnancy. Standard pre-conception counselling will be picked up at that review.
• Aura and contraception: no aura now, but if visual zig-zags, flashing lights, blind spots, numbness or speech disturbance ever appear before/during a headache, ring the surgery — that would change the advice on combined hormonal contraception (CHC) if she ever uses one (CHC contraindicated in migraine with aura).

1. g) Referral. Not indicated today. Neurology only if red flags develop, atypical features emerge, diagnosis becomes uncertain, optimal primary-care treatment fails, or preventative treatment is being considered in pregnancy.

B4. Ideal close

“So — we’ve agreed it’s migraine, you’ll start sumatriptan 50 mg and ibuprofen 400 mg at the start of each headache, you’ll keep a diary, and we’ll catch up in about a month. I’ll text you the diary and a leaflet. You know what to look out for in the meantime. Anything else before we wrap up?”

PART C – GOLDEN HISTORY-TAKING QUESTIONS

1. “Tell me about these headaches — when did they start, and what’s been happening?”
2. “Can you talk me through a typical headache from start to finish — how long does each one last?”
3. “Whereabouts is the pain, and what does it feel like?”
4. “How bad is it at its worst, and what does it stop you doing?”
5. “Do you get any warning before it starts — flashing lights, zig-zags, blind spots, tingling, numbness or trouble speaking?”
6. “What else happens with the headache — feeling sick, bothered by light or noise, anything else?”
7. “Have you ever had a headache that came on suddenly, like a clap of thunder, reaching its worst within a few minutes? Any fever, stiff neck, rash, weakness, numbness, vision change or a fit? Any head injury recently? Any headache that’s worse when you cough, bend, sneeze or lie flat?”
8. “What have you been taking for it, how often, and does it help?”
9. “Periods, contraception, anything in your family with similar headaches?”
10. “How is this affecting your life — work, sleep, things you usually enjoy?”
11. “Was there anything in particular on your mind about these headaches — anything you were worried it might be?”
12. “What were you hoping we might do today?”

PART D – NIGHT-BEFORE MANAGEMENT CHECKLIST

• Explanation: migraine without aura, positive diagnosis from history, common, often familial [ ]
• ICE addressed: name the aunt; validate brain-tumour fear; explain why no scan today [ ]
• First-line drug + exact dose: sumatriptan 50 mg PO + ibuprofen 400 mg PO at onset (max sumatriptan 300 mg/24 h) [ ]
• Key safety warning: stop sumatriptan and ring us if chest, throat or jaw tightness/heaviness [ ]
• MOH counselling: ≤2 days per week of acute treatment [ ]
• Antiemetic if offered: prochlorperazine 10 mg PO preferred over metoclopramide in young women (MHRA/CHM 2013 dystonia warning) [ ]
• Safety-net: thunderclap; fever + neck stiffness; focal neurology; change in pattern; much worse on bending/coughing/lying flat → 999 or A&E same day; not improving → ring surgery [ ]
• Headache diary: 8 weeks minimum [ ]
• Follow-up: 4–6 weeks [ ]
• Pre-conception note + aura/CHC red flag [ ]
• Health promotion: regular meals, hydration, consistent sleep, caffeine consistency, stress [ ]
• Referral threshold: neurology only if red flags, atypical features, diagnostic doubt, primary-care failure, or pregnancy [ ]

PART E – CASE VARIATIONS

1. Aura version. Same presentation but with preceding visual zig-zags lasting 20 minutes. Diagnosis becomes migraine with aura; CHC absolutely contraindicated; aspirin and triptan still acceptable; triptan at headache onset, not at aura onset (unless they start together).
2. Pregnant version. Same patient at 16 weeks pregnant. Paracetamol first-line; ibuprofen acceptable only before 20 weeks; sumatriptan is the preferred triptan in pregnancy; avoid aspirin and opioids; preventative treatment NOT to be initiated in primary care — seek specialist advice. Screen for pre-eclampsia features.
3. Frequent attacks / preventative threshold. 4–5 attacks per month with significant impact despite acute treatment, AND analgesia use approaching MOH territory. Adds preventative discussion: propranolol 80–160 mg daily in divided doses OR topiramate 50–100 mg daily (with full MHRA Pregnancy Prevention Programme counselling — she is of childbearing potential and not yet trying) OR amitriptyline 25–75 mg at night. MOH must be excluded/managed first.
4. Patient declines triptan / wants only natural treatment. Tests shared decision-making. Falls back to simple analgesia (ibuprofen 400 mg or paracetamol 1 g), riboflavin 400 mg once daily as an adjunct, lifestyle measures, explicit “come back if not enough” safety-net.
5. Telephone modality. Same case by phone — removes visible cues. Tests whether the candidate compensates with explicit ICE questions and listening for voice cues (the wobble when the aunt is mentioned). Brain-tumour fear harder to surface; reveal trigger must be an explicit open ICE question.

PART F – WHY CANDIDATES FAIL THIS CASE

• Trap: rushing into a closed checklist red-flag screen at minute one → fails Data Gathering and Relating to Others. Fix: open mode for the first 60 seconds (“tell me what’s been happening”), THEN signpost the red-flag screen.
• Trap: agreeing to a brain scan to “reassure” her → fails Clinical Management. Sounds patient-centred but is unsafe and models poor stewardship. Fix: validate the fear by name; explain the positive diagnosis from pattern; offer a robust safety-net and follow-up as the real reassurance.
• Trap: prescribing metoclopramide three times daily without flagging or considering the MHRA dystonia warning in young women → fails Clinical Management. Fix: prefer prochlorperazine 10 mg PO, or know the MHRA 2013 restriction (max 5 days, 10 mg up to TDS).
• Trap: vague management (“take some painkillers and we’ll see how you go”) → fails Clinical Management. Fix: name the drugs, doses, trigger to take them, warning to stop, day-per-week limit, and review date.
• Trap: insisting on a face-to-face appointment “to be on the safe side” → fails Clinical Management (over-cautious indicator). Fix: recognise this as OVER-CAUTIOUS; conclude remotely with a specific red-flag-keyed safety-net; offer face-to-face only with a stated clinical reason.

 

PART F – Revision Card

32 yr old teacher, 6 months of unilateral throbbing headaches with nausea; fears brain tumour, wants scan.

Diagnosis: Episodic migraine without aura | Differentials: tension-type headache; medication-overuse headache (MOH); secondary headache.

Must-ask history — 8 golden questions

1. “When did they start, what happens in an attack?”
2. “How long does each one last?”
3. “Where is the pain, what does it feel like?”
4. “How bad at worst — what does it stop you doing?”
5. “Any aura — flashing lights, zig-zags, tingling, numbness, speech?”
6. “Sick? Bothered by light or noise?”
7. “What have you taken, how often, does it help?”
8. “What were you worried it might be?”

Red flags to screen actively

• Thunderclap onset
• Focal neurology (weakness/numbness/speech/vision/balance)
• Fever, neck stiffness, non-blanching rash
• Recent head trauma
• Worse on bending/coughing/sneezing/lying flat
• Change in pattern; immunocompromise; cancer history

ICE (Ideas, Concerns and Expectations) — what to address

• Idea (migraine, like mum) → “You wondered whether it might be migraine — I think you’re right.”
• Concern (brain tumour, aunt) → “You mentioned your auntie — I can understand why these have frightened you.”
• Expectation (a scan) → “I’m not doing a scan today — let me explain why.”

Management — say this

• Face-to-face: OVER-CAUTIOUS. Do not insist; safety-net instead. Offer only with a stated clinical reason.
• Explain: “This fits very well with migraine — the brain becomes briefly oversensitive to pain, light, sound and movement.”
• First-line: Sumatriptan 50 mg PO + ibuprofen 400 mg PO at headache onset. Repeat sumatriptan after ≥2h only if migraine recurs (not same attack). Max 300 mg/24h. Warning: “Stop and ring us if any chest, throat or jaw tightness or heaviness.”
• Add-on if needed: Prochlorperazine 10 mg PO for nausea — preferred over metoclopramide in young women (MHRA — Medicines and Healthcare products Regulatory Agency — August 2013: dystonia risk; max 5 days, 10 mg TDS).
• AVOID: opioids (cause MOH); ergotamine; brain MRI (magnetic resonance imaging) / CT (computed tomography) for reassurance — NICE (National Institute for Health and Care Excellence) NG150 advises against.
• Diary 8 weeks; regular meals, hydration, consistent sleep/caffeine.
• Follow-up: 4–6 weeks — diary, efficacy, side effects, triggers.

Safety-net — exact triggers

• 999/A&E same day: thunderclap; fever + neck stiffness or non-blanching rash; weakness/numbness/speech/vision change; fit; reduced alertness.
• Ring surgery: much more frequent or worse; different pain; worse on bending/coughing/lying flat; treatment not working.
• Earlier review: acute medication >2 days/week (MOH risk).

The pivot — what this case really tests Positive diagnosis from history; name the brain-tumour fear before refusing the scan; safety-net thoroughly.

Clear Pass move — what lifts you from Pass to Clear Pass Name the aunt and acknowledge the brain-tumour fear BEFORE explaining no scan is needed — heard first, then explained.

Anchor phrase to memorise “This fits very well with migraine — let me explain why, and what we’ll do about it.”

 

Important Disclaimer

This MedDigest consultation is a fictional case, created for educational and revision purposes only. It should not be used for clinical decision-making or as a substitute for your own clinical judgment.

This content is an independent educational resource designed by MedDigest to illustrate clinical principles. It has not been produced, reviewed, or endorsed by NICE or the Royal College of General Practitioners.

Medicine is constantly evolving. For definitive recommendations, always refer to the latest official guidelines and your local clinical protocols.

MedDigest and its authors cannot accept responsibility for any loss or injury resulting from the use of the information contained herein.

 

References

Primary UK clinical guidance

National Institute for Health and Care Excellence (2021) Headaches in over 12s: diagnosis and management. NICE guideline NG150. London: NICE. Available at: https://www.nice.org.uk/guidance/ng150 (Accessed: 26 May 2026).

Joint Formulary Committee (2026) British National Formulary. London: BMJ Group and Pharmaceutical Press. Available at: https://bnf.nice.org.uk (Accessed: 26 May 2026).

National Institute for Health and Care Excellence (2025) Migraine. Clinical Knowledge Summary. London: NICE. Available at: https://cks.nice.org.uk/topics/migraine/ (Accessed: 26 May 2026).

National Institute for Health and Care Excellence (2025) Headache – assessment. Clinical Knowledge Summary. London: NICE. Available at: https://cks.nice.org.uk/topics/headache-assessment/ (Accessed: 26 May 2026).

UK regulatory and safety guidance

Medicines and Healthcare products Regulatory Agency (2013) Metoclopramide: risk of neurological adverse effects — restricted dose and duration of use. Drug Safety Update. London: MHRA. Available at: https://www.gov.uk/drug-safety-update/metoclopramide-risk-of-neurological-adverse-effects (Accessed: 26 May 2026).

Medicines and Healthcare products Regulatory Agency (2024) Topiramate (Topamax): introduction of new safety measures, including a Pregnancy Prevention Programme. Drug Safety Update. London: MHRA. Available at: https://www.gov.uk/drug-safety-update/topiramate-topamax-introduction-of-new-safety-measures-including-a-pregnancy-prevention-programme (Accessed: 26 May 2026).

Medicines and Healthcare products Regulatory Agency (2023) Non-steroidal anti-inflammatory drugs (NSAIDs): potential risks following prolonged use after 20 weeks of pregnancy. Drug Safety Update. London: MHRA. Available at: https://www.gov.uk/drug-safety-update/non-steroidal-anti-inflammatory-drugs-nsaids-potential-risks-following-prolonged-use-after-20-weeks-of-pregnancy (Accessed: 26 May 2026).

Specialty society guidelines

Ahmed, F., Gaul, C., García-Moncó, J.C., Sommer, K. and Martelletti, P. (2019) ‘An open-label prospective study of the real-life use of onabotulinumtoxinA for the treatment of chronic migraine: the REPOSE study’, The Journal of Headache and Pain, 20(1), p. 26. [British Association for the Study of Headache guideline source.]

Scottish Intercollegiate Guidelines Network (2023) Pharmacological management of migraine. SIGN publication no. 155. Edinburgh: SIGN. Available at: https://www.sign.ac.uk/our-guidelines/pharmacological-management-of-migraine/ (Accessed: 26 May 2026).

Faculty of Sexual and Reproductive Healthcare (2019, amended 2023) FSRH Guideline: Combined Hormonal Contraception. London: FSRH. Available at: https://www.fsrh.org/standards-and-guidance/documents/combined-hormonal-contraception/ (Accessed: 26 May 2026).

International classification

Headache Classification Committee of the International Headache Society (2018) ‘The International Classification of Headache Disorders, 3rd edition’, Cephalalgia, 38(1), pp. 1–211. doi: 10.1177/0333102417738202.

Patient information

The Migraine Trust (2020) About migraine. London: The Migraine Trust. Available at: https://migrainetrust.org/understand-migraine/ (Accessed: 26 May 2026).

RCGP examination guidance

Royal College of General Practitioners (2025) Simulated Consultation Assessment (SCA): candidate guide. London: RCGP. Available at: https://www.rcgp.org.uk/mrcgp-exams/sca (Accessed: 26 May 2026).