Station 50
Amanda Walsh
Age: 16 years old female
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Ask about the location, onset, and nature of the headache (e.g. throbbing, stabbing, dull, sharp, thunderclap).
- Ask whether the headache radiates and whether it is improving, worsening, or staying the same.
- Ask if the headache is constant or intermittent, how long each episode lasts and how frequently it occurs (e.g. weekly or monthly).
- Ask about any aura symptoms before the headache, such as visual disturbances (zigzag lines, flashing lights), or sensory changes (numbness, tingling).
- Ask about associated symptoms, including nausea, vomiting, photophobia, visual disturbance, fever, rash, and neck stiffness.
- Explore potential triggers, such as stress, emotional distress, or menstruation.
- Ask if the headache wakes the patient from sleep, which may be a red flag.
- Screen for neurological symptoms, such as unilateral weakness, numbness, or slurred speech.
- Ask about any recent head trauma, particularly within the last 3 months (to rule out subdural haematoma).
- Ask what medications the patient is using for headache relief and how often they’re used, to explore the possibility of medication overuse headache (e.g. using NSAIDs or paracetamol ≥15 days/month or triptans/opioids ≥10 days/month).
- Ask how the headache is impacting daily life, including schoolwork and concentration.
- Ask about lifestyle factors, including smoking, alcohol, or recreational drug use.
- Give a diagnosis of migraine headache flare, likely triggered by the combined oral contraceptive pill (COCP)
Example of explanation to patient
Thanks for sharing all of that with me, Amanda, it sounds like these headaches have been quite tough to deal with, especially while preparing for your A levels.
From everything you’ve described, this sounds like a migraine, and it’s quite possible that your combined contraceptive pill (Microgynon) is contributing to the increased frequency. Sometimes, this type of contraceptive pill can trigger migraines or make them worse. So, I’d recommend stopping the pill for now, and we’ll arrange a follow-up to talk about other contraceptive options. In the meantime, it’s important to use condoms to stay protected.
You mentioned that stress might be a factor, and you’re absolutely right, stress can trigger or worsen migraines. So,things like managing study time, staying hydrated, reducing screen time, getting enough sleep, and taking breaks for rest or light exercise can all make a difference.
To help track other factors that might be triggering your headaches and how often they’re happening, I’d suggest keeping a headache diary. It’s really useful when looking at patterns or deciding if further treatment is needed.
For now, I’d like to prescribe you the nasal spray version called sumatriptan, similar to what you’ve used before, to take when the headaches start, it works quite quickly. If the headache isn’t fully controlled, you can also take it alongside ibuprofen for better relief.
If things don’t settle down or your headaches become more frequent, we may need to refer you to a paediatric (children) specialist to explore preventive treatment, something that helps stop the migraines before they start.
I’d also like to bring you in for a face-to-face appointment so I can check your blood pressure, examine your nerves, and look at the back of your eyes properly, just to make sure there’s nothing else going on, if that’s alright with you.
I’ll arrange a follow-up in two weeks to see how you’re getting on, but if anything changes in the meantime, like your headaches becoming more severe, lasting longer, or feeling different, please don’t hesitate to get back in touch straight away.
Management
Management
- Offer a face-to-face appointment to perform a full neurological examination, including fundoscopy to check for papilloedema or other abnormalities.
- Recommend keeping a headache diary to monitor frequency, duration, triggers, and response to treatment.
- Advise stopping the combined oral contraceptive pill (COCP) due to the potential link with migraine and arrange a follow-up to discuss alternative contraception; recommend using condoms in the interim.
- Offer nasal sumatriptan for acute migraine relief; consider adding prochlorperazine or metoclopramide (unlicensed in 18s and under) if nasal sumatriptan alone is ineffective.
- NSAIDs can also be used in combination with nasal sumatriptan if nasal sumatriptan alone is ineffective.
- Provide lifestyle advice, including stress management, screen time reduction, hydration, adequate rest, and regular physical activity, as these may help reduce headache frequency.
- Explain that if symptoms persist or become more frequent despite these measures, a referral to paediatrics may be needed to assess suitability for migraine prophylaxis.
- Provide clear safety netting advice: seek urgent help if headaches worsen suddenly, change in character, are associated with neurological symptoms, or become unresponsive to treatment.
- Arrange a follow-up in 2 weeks to review progress and headache diary entries.
Learning point from this station:
This case highlights the importance of reviewing the suitability of the combined oral contraceptive pill (COCP) in patients with a history of migraine, particularly in adolescents.
According to the Faculty of Sexual and Reproductive Healthcare (FSRH) UK Medical Eligibility Criteria (UKMEC):
- Migraine with aura is classified as UKMEC 4 – a category in which the health risks are considered unacceptable, and COCP should not be used.
- Migraine without aura is considered UKMEC 2 when initiating COCP – meaning the benefits generally outweigh the risks, and it is acceptable to start the COCP, provided there is close monitoring for any change in migraine pattern (e.g. development of aura or worsening severity). This is likely why COCP was initially prescribedfor the patient in this case.
- If a patient is already taking COCP and develops new or worsening migraine without aura, this becomesUKMEC 3 – a category where the risks usually outweigh the benefits, and continued use is not routinely recommended without expert input. This would warrant stopping the COCP and reviewing alternative contraceptive options.
This station reinforces the need to:
- Take a clear migraine history, including presence or absence of aura
- Understand how hormonal contraception may impact migraine patterns
- Use UKMEC guidance to inform safe prescribing
- Stop or switch contraception if red flags emerge (e.g. aura, worsening headaches)
- Offer patient-centred counselling about contraception, especially in adolescents
Combined oral contraceptive pills (COCPs) are associated with an increased risk of cerebral venous sinus thrombosis (CVST) and stroke, although these are rare complications. If a patient on COCP presents with a sudden-onset, daily, disabling headache that does not respond to analgesia, especially if accompanied by neurological symptoms, CVST or stroke should be considered in the differential diagnosis.