New Headache (OSCE focused)

Candidate Instructions:You are the medical student in an Acute Medical Unit. A 35-year-old patient has presented with a new headache. Take a focused history and explain your initial assessment and management.

Key History Points 📝

• ⏱️ Onset & Timing: Sudden “thunderclap” headache (SAH), gradual (tumour, tension), recurrent (migraine/cluster).
• 📍 Location & Radiation: Unilateral (migraine, cluster), occipital (raised ICP/bleed), global (tension).
• 📈 Severity & Progression: Worse with coughing, exertion, or lying flat → think raised ICP.
• ⚠️ Red Flags: Fever, photophobia, neurological deficit, altered consciousness, seizures, pregnancy/puerperium, immunosuppression, new headache >50 years.
• 📜 PMHx & Risk Factors: HTN, trauma, cancer, anticoagulation, infections, recent LP.
• 💊 Medications: Anticoagulants, OCP/HRT, analgesia overuse.
• 🌡️ Associated Symptoms: Nausea/vomiting, photophobia, neck stiffness, aura, vision loss, jaw claudication, scalp tenderness.

Focused Examination 👀

• 🧍 General inspection: distress, photophobia, meningism (Kernig’s, Brudzinski’s).
• 🧠 Neurological exam: cranial nerves, motor, sensory, reflexes, coordination.
• 👁️ Fundoscopy: papilloedema = raised ICP.
• 🩺 Vitals: fever, BP, meningitis red flags.
• Temporal artery palpation in >50y with scalp tenderness/visual disturbance.

Investigations 🔬

• 🧪 Bloods: FBC, U&E, CRP, ESR (temporal arteritis), clotting.
• 🧠 CT Head: urgent if sudden onset, neuro deficit, seizure, raised ICP.
• 💉 Lumbar puncture: if meningitis or SAH suspected but CT normal (only if no raised ICP).
• 👓 ESR/CRP: very high in temporal arteritis.

Initial Management 🚑

• ⚠️ Red flag? → Admit + urgent imaging + senior review.
• 💊 Analgesia: paracetamol, NSAID (if appropriate).
• 🤕 Migraine: triptan + NSAID/paracetamol + antiemetic.
• 🔥 Temporal arteritis: immediate high-dose steroids (prednisolone) to prevent blindness.
• 🧪 Suspected meningitis: IV ceftriaxone ± dexamethasone before LP if unstable.
• 🩸 SAH: neurosurgical referral, BP control, nimodipine.

Examiner’s Marking Guide 📋

• Structured history covering onset, red flags, and associated symptoms.
• Checks for meningitis and temporal arteritis in appropriate age groups.
• Plans appropriate imaging (CT before LP if raised ICP suspected).
• Mentions urgent management: steroids for arteritis, antibiotics for meningitis, nimodipine for SAH.
• Clear safety-netting and explanation to patient.

🧑‍⚕️ Case Examples - New Headache

• Case 1 (Subarachnoid Haemorrhage): 💥 A 52-year-old woman develops sudden, severe “thunderclap” headache while gardening. She vomits and briefly loses consciousness. CT head shows subarachnoid blood. Diagnosis: Aneurysmal SAH. Teaching point: Always suspect SAH in sudden-onset severe headache; confirm with CT ± LP if CT negative.
• Case 2 (Giant Cell Arteritis): 🔥 A 72-year-old woman reports new unilateral temporal headache with scalp tenderness and jaw claudication. Vision suddenly blurs in the left eye. ESR > 100. Diagnosis: Temporal arteritis (GCA). Teaching point: Treat immediately with high-dose steroids to prevent permanent vision loss; biopsy confirms diagnosis.
• Case 3 (Raised Intracranial Pressure - Brain Tumour): 🧠 A 48-year-old man develops daily morning headaches with vomiting, worse when coughing. Neuro exam shows papilloedema. MRI reveals a frontal lobe mass. Diagnosis: Headache secondary to intracranial tumour. Teaching point: Morning headache + papilloedema = raised ICP until proven otherwise; urgent neuro referral needed.
• Case 4 (Meningitis): 🦠 A 30-year-old man presents with acute headache, photophobia, fever, and neck stiffness. Kernig’s sign positive. LP shows neutrophilia and low CSF glucose. Diagnosis: Bacterial meningitis. Teaching point: Headache + fever + neck stiffness is meningitis until excluded; treat empirically with IV ceftriaxone ± dexamethasone.
• Case 5 (Medication Overuse Headache): 💊 A 40-year-old woman with migraine history reports near-daily headaches for 3 months. She uses triptans and codeine most days. Headaches now dull, bilateral, and persistent. Diagnosis: Medication overuse headache. Teaching point: Suspect in chronic daily headache with analgesic overuse; management = withdrawal + preventive migraine therapy.