PLAB 2 Neurology: Acute Headache Management Guidelines for OSCE

PLAB 2 Neurology: Acute Headache Management Guidelines for OSCE Success

Headaches are an incredibly common presentation in both primary care and emergency departments, making them a high-yield topic for the PLAB 2 exam. As an examiner, I've seen countless candidates struggle with approaching a patient presenting with a headache, often missing critical red flags or failing to provide a structured, guideline-based management plan. Mastering acute headache management is crucial not just for your exam, but for your future clinical practice.

This blog post will guide you through the essential guidelines for managing acute headaches in a PLAB 2 OSCE setting, focusing on systematic history taking, identifying red flags, and formulating appropriate management plans.

The OSCE Scenario: A Patient with Acute Headache

You'll likely encounter a patient complaining of a new or worsening headache. Your task is to arrive at a provisional diagnosis, rule out serious pathology, and provide safe and effective management. This requires a sharp focus on history, examination, and communication.

1. History Taking: The Foundation of Headache Diagnosis

Your history is paramount. Go beyond the basic SOCRATES (Site, Onset, Character, Radiation, Associations, Time course, Exacerbating/Relieving factors, Severity) and delve into key areas that differentiate benign from dangerous headaches.

Crucial Questions to Ask:

• Onset: Was it sudden (e.g., 'thunderclap' headache, reaching peak intensity within seconds to minutes)? This is a major red flag for Subarachnoid Haemorrhage (SAH).

• Character: Pulsating (migraine), band-like (tension), sharp/stabbing (trigeminal neuralgia).

• Associated Symptoms:

  • Neurological: Weakness, numbness, visual changes (double vision, field loss, transient loss), speech difficulty, altered consciousness, seizures. (Red flags!)

  • Systemic: Fever, neck stiffness, rash (meningitis), weight loss, jaw claudication, scalp tenderness (temporal arteritis).

  • Autonomic (Migraine/Cluster): Photophobia, phonophobia, osmophobia, nausea, vomiting, unilateral lacrimation, conjunctival injection, ptosis.

• Previous Headaches: Is this a new type of headache or similar to previous ones?

• Triggers: Stress, specific foods, alcohol, sleep deprivation, hormonal changes.

• Medication History: Any new medications? Overuse of analgesics (medication overuse headache)? Anticoagulants (risk of intracranial bleed)?

• Past Medical History: Hypertension, diabetes, HIV/immunocompromised, history of malignancy, head trauma.

2. Identifying Red Flags: When to Worry!

This is perhaps the single most important aspect of acute headache management in PLAB 2. Missing a red flag can lead to patient harm and exam failure. Always screen for these:

• Sudden onset 'Thunderclap' headache: Reaches maximal intensity within 1 minute. ALWAYS suspect SAH until proven otherwise.

• New onset headache in patient > 50 years: Consider Giant Cell Arteritis (Temporal Arteritis) – especially with jaw claudication, visual loss, scalp tenderness, or polymyalgia rheumatica symptoms.

• Headache with focal neurological deficits: Weakness, sensory loss, visual field defect, speech disturbance, pupillary changes. Suggests structural lesion (e.g., tumour, stroke).

• Headache with fever, neck stiffness, rash, photophobia: Consider Meningitis or Encephalitis.

• Headache with papilloedema: Raised intracranial pressure (e.g., tumour, idiopathic intracranial hypertension).

• Headache with altered mental status or decreased GCS.

• Headache in immunocompromised patients (e.g., HIV, transplant recipients): Increased risk of opportunistic infections (e.g., toxoplasmosis, cryptococcosis).

• Headache following head trauma.

• Headache worsening despite adequate analgesia.

• Progressively worsening headache.

If any red flags are present, urgent hospital admission and investigation (e.g., CT head, lumbar puncture) are mandatory.

3. Examination: Focused and Relevant

• General inspection: Look for signs of distress, rash, pallor.

• Vital signs: Temperature, pulse, blood pressure. (Fever, hypertension).

• Neurological examination:

  • Cranial nerves: Particularly fundoscopy for papilloedema, visual fields.

  • Motor and sensory system: For focal deficits.

  • Cerebellar signs.

• Neck stiffness: (Kernig's and Brudzinski's signs if appropriate, but general assessment for stiffness is usually sufficient in OSCE).

• Temporal arteries: Palpate for tenderness/thickening if GCA is suspected.

4. Management: Tailored and Guideline-Based

A. If Red Flags are Present:

• Urgent referral to A&E/Emergency Department.

• Explain concerns to the patient clearly and empathetically.

• Do not delay. Arrange transport (e.g., ambulance if necessary).

B. If No Red Flags (Likely Primary Headache):

Common Primary Headaches:

1. Migraine:

   • Diagnosis: At least 5 attacks, lasting 4-72 hours, with at least two of (unilateral, pulsating, moderate/severe intensity, aggravated by physical activity) and at least one of (nausea/vomiting, photophobia and phonophobia).

   • Acute Management:

     • Simple analgesia: Paracetamol or NSAIDs (ibuprofen, naproxen) first-line.

     • Triptans: (e.g., Sumatriptan, Zolmitriptan) are specific migraine abortive medications, especially if simple analgesia is ineffective. Advise taking at onset of headache, but not during aura. Contraindicated in ischaemic heart disease, uncontrolled hypertension.

     • Antiemetics: (e.g., Metoclopramide, Prochlorperazine) if nausea/vomiting is significant. Can be given orally or rectally.

     • Combination medications: Some contain paracetamol, aspirin, and caffeine.

   • Non-pharmacological: Rest in a dark, quiet room, cold compress.

   • Prevention (brief mention): Propranolol, Topiramate, Amitriptyline for frequent or severe migraines.

2. Tension-Type Headache (TTH):

   • Diagnosis: Bilateral, pressing/tightening (non-pulsating), mild/moderate intensity, not aggravated by physical activity, no nausea/vomiting, no more than one of photophobia or phonophobia.

   • Acute Management: Simple analgesia (paracetamol, NSAIDs). Avoid overuse to prevent medication overuse headache.

   • Non-pharmacological: Stress management, relaxation techniques, adequate sleep.

3. Medication Overuse Headache (MOH):

   • Consider if: Headaches are daily or almost daily, and patient is overusing acute headache medications (e.g., simple analgesics >15 days/month, triptans/opioids >10 days/month).

   • Management: Withdrawal of the overused medication. This can be challenging and may require specialist referral.

5. Communication and Safety-Netting

• Explain findings: Reassure the patient if no red flags are found, explain the likely diagnosis (e.g., migraine).

• Management plan: Clearly outline medication use, non-pharmacological advice.

• Safety-netting is crucial: Advise the patient on when to seek immediate medical attention – any new, severe symptoms, worsening headache, fever, neck stiffness, neurological changes. Provide clear instructions on what symptoms to look out for.

• Follow-up: Arrange a follow-up if needed, or advise on when to review with their GP for ongoing management (e.g., if headaches become more frequent or severe).

Key Takeaways for PLAB 2:

• Prioritise Red Flags: Always, always screen for and act upon red flags first.

• Systematic Approach: Follow a logical history, examination, and management structure.

• Know Your Guidelines: Be familiar with NICE guidelines for migraine and headache management, particularly for acute treatment.

• Excellent Communication: Explain clearly, empathetically, and provide robust safety-netting.

By following these guidelines, you'll not only excel in your PLAB 2 OSCEs but also develop a crucial skill set for your future practice as a doctor in the NHS. Good luck!

Disclaimer: This information is intended for educational purposes for medical students preparing for exams and does not constitute medical advice. Always refer to current national and local guidelines for clinical practice.