SCA practice case · Video consultation
“I’ve got a headache nearly every day and I’m taking painkillers constantly — nothing touches it”
The candidate brief
This is what you would read in the 3-minute window before the patient connects. Read it once, note two or three hypotheses and one thing you must not miss, then stop.
Patient
Rowena Page · 34 years · female
Setting
Video consultation — frequent headaches with heavy analgesic use
Past history
- Migraine (long-standing)
Medication
- Co-codamol — most days
- Triptan — most days
Allergies
None recorded
Recent notes
⚠ Frequent co-codamol and triptan requests on repeat record. No headache diary. Practice nurse, yesterday: BP 122/76, pulse 72 regular, temperature 36.6 °C. Optometrist, last month (routine eye examination): optic discs healthy, no papilloedema.
Reason for contact
Daily headache. “Can I have something stronger?”
Practise this case
The full case is in the Hot Seat with the Gold plan. You get a 12-minute timer, a role-player script with facts released only when asked, examiner checkpoints by the three RCGP domains, a model consultation and the guidance behind it.
What this case tests
Show the learning points (spoiler: read after you have practised)
A near-daily headache in someone with a primary headache disorder who uses acute analgesics or triptans frequently is the picture of MEDICATION-OVERUSE HEADACHE (MOH), but the FIRST step is always to EXCLUDE secondary/red-flag headache: thunderclap onset (SAH), new focal neurology or raised-ICP/papilloedema features (morning headache, worse lying/Valsalva, vomiting), systemic features (fever, weight loss, immunosuppression, cancer history), a substantial change in the characteristics of the headache (NICE CG150), and GCA features in older patients. Recognise MIGRAINE (moderate-severe, often unilateral/throbbing, with nausea and photophobia/phonophobia, aggravated by activity, ± aura) and note when an episodic pattern has become near-daily. The key second diagnosis is MOH: a chronic daily/near-daily headache where triptans/opioids/combination analgesics are used on ≥10 days/month (or simple analgesics on ≥15 days/month) for over 3 months, with the OVERUSED MEDICATION now PERPETUATING the headache — so "something stronger" or more frequent painkillers makes it worse, and the diagnosis must be made rather than the analgesia escalated. Manage MOH by explaining the cycle and supporting WITHDRAWAL of the overused acute drug (NICE CG150: all overused acute drugs stopped abruptly, not gradually, for at least 1 month; specialist referral for strong-opioid overuse; review at 4–8 weeks), with a clear warning that the headache typically WORSENS for days-to-weeks before improving (expected and temporary), plus support and review. Simultaneously optimise migraine care — sparing acute treatment to avoid re-overuse, PROPHYLAXIS where frequent (propranolol, amitriptyline, topiramate — noting topiramate’s teratogenicity, the MHRA 2024 pregnancy prevention programme and reduced contraceptive efficacy; candesartan as an off-label alternative per BASH; riboflavin 400 mg daily may help per CG150; no opioids for acute migraine, CG150; ask about aura, UKMEC 4 for combined hormonal contraception), trigger/sleep/lifestyle measures and a headache diary. The hidden agenda is the desperate wish for a stronger painkiller; explain compassionately why that worsens MOH, support a realistic withdrawal plan, and safety-net for red flags.
The guidance behind it
Similar SCA cases
gpreasoning.uk is not affiliated with or endorsed by the RCGP. Our cases are original teaching material written for practice; none is an exam recall. For anything official about the SCA, check the RCGP SCA pages.