Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year Doctor working in General Practice. Your next patient is Frederick Zhang, a 33-year-old male with a history of migraines who presents today complaining of recent episodes of severe headache. Please take a history and perform a relevant examination.
Patient History:
Frederick Zhang (Freddy), 33 y/o M, Chief Financial Officer of a tech startup.
You have been experiencing sudden onset, recurrent headaches of excruciating intensity (10/10 pain) over the right side of your head. The headaches started two weeks ago and occur twice a day on average, lasting an hour on most occasions. The episodes have not become more frequent or painful than when they started. You think that the character of these headaches is best described as a 'stabbing' nature and have noticed the pain is particularly intense around the region of your right eye. The pain makes you restless, and its intensity distracts you from your work; you are forced to take breaks in a room isolated from other people during attacks. Your colleagues at work can always tell when you're having an attack even if you try to hide it – they say it looks like you're crying on just one side of your face. You have not noticed any relation between these attacks and the time of day and cannot pinpoint a specific trigger.
A systems review will reveal an absence of:
Limb or facial weakness,
Visual, auditory, olfactory or gustatory disturbance,
Hip or shoulder girdle pain, scalp tenderness or jaw claudication.
Ideas, Concerns, Expectations:
You have had issues with migraines in the past, but these headaches feel different – you are not getting the same visual symptoms or urge to avoid light. You are particularly concerned about the effect these attacks have on your work. You must be able to carry on work without distractions, and you need life to be 'back to normal' as soon as possible.
Past Medical History:
Migraines – these headaches feel different, however. No history of head trauma.
Drug History:
None.
No known drug allergies.
Family History:
Father has chronic hepatitis C.
Social History:
You smoke one pack of cigarettes a day for 15 years.
You drink one bottle of wine per week – an important, enjoyable part of your lifestyle.
You live with your wife and three children.
You work as a Chief Financial Officer of a tech startup.
Examination Findings:
A full cranial nerve/ neurological examination will reveal no significant abnormality. GCS 15/15.
Differentials:
Cluster headache
Migraine
Most serious causes of a headache to consider and rule out:
Vascular:
Subarachnoid haemorrhage
Cerebral venous sinus thrombosis
Giant cell arteritis
Malignant hypertension
Carotid artery dissection
Infective:
Meningitis
Encephalitis
Intracranial abscess
Traumatic:
Head trauma
Neoplastic
Neoplastic space-occupying lesion
Ophthalmological:
Acute angle closure glaucoma
This is a typical history depicting a cluster headache – a severe, sharp, unilateral headache occurring in 'clusters' which causes autonomic symptoms and restlessness. Mr Zhang is particularly at risk of developing cluster headaches: male sex, smoking and the age of 30 are risk factors for this condition.
Investigations: