MRCGP SCA Consultation Skills Course
Station 3 · Headache
Video consultation · Undifferentiated presentations · Gender, reproductive and sexual health · Long-term conditions · Circuit 1 · 09:40–11:00 · 13-minute station
A 36-year-old on the combined pill has daily headaches, takes painkillers most days, and the nurse has found a blood pressure of 168/104.
Candidate brief
Read this as you would in the exam. One to two minutes' reading, then ten minutes. You may ask the patient for examination findings; there is no reference material.
| Patient | Priyanka Mehta, 36, solicitor |
| Reason for appointment | Headaches (booked by patient); nurse note this morning: "BP 168/104 and 164/102 at pill check — please review before re-issuing" |
| PMH | Migraine without aura (diagnosed at 24). Nil else. BMI 24. Non-smoker |
| Medication | Combined pill (ethinylestradiol 30 mcg/levonorgestrel), 12 years. Buys paracetamol/codeine and ibuprofen over the counter. Allergies: none |
| Recent entries | Two years ago: BP 128/82. Family history: father hypertension. No previous headache review recorded |
Role-player script — tutors only
Delegates: please do not open this section until you have consulted at this station.
Open the role-player script (605 words)
Persona and manner
- Precise, courteous, slightly tense; used to being in control; checks her phone for the time once. Wants efficient answers.
- Not hostile, but resists being told to stop the pill — it has worked for twelve years and she has a heavy caseload.
Opening line — say this verbatim
- "The nurse said my blood pressure was high and she couldn't give me my pill until I'd seen a doctor. I'm also getting headaches most days, which is why I came in — I need something stronger than what I'm taking."
Volunteer freely if given the space
- Headaches most days for about four months: a dull, pressing pain across the forehead, worse by evening; 'a real migraine' about twice a month with nausea and needing to lie down.
- Takes paracetamol-codeine 'most days, sometimes twice', and ibuprofen 'on top' when it is bad — she has kept it in her desk drawer for months.
- Work is 'intense': a big case, long hours, screens all day, coffee 'constantly', sleeping five or six hours.
Only if asked
- Counting honestly: painkillers on 18–20 days a month for at least three months.
- No visual aura; migraines have never had aura. No thunderclap onset; no headache on waking or with coughing/straining; no vomiting except with migraine; no fever; no neck stiffness; no weakness or numbness; no visual loss; no change in personality; no headache that wakes her.
- No previous high readings that she knows of; no palpitations, sweats or flushing; no chest pain; no breathlessness; no ankle swelling; no snoring reported by partner.
- The pill: uses it 'because I've always used it'; married; not planning pregnancy for two or three years; would consider 'something that doesn't mess with my periods'.
- Father had a stroke at 62 on top of his blood pressure. Mother well.
- Alcohol: two or three glasses of wine most evenings 'to switch off'. No drugs. Not pregnant (period two weeks ago, regular on the pill).
- Mood: stressed, not depressed; sleeps badly because of work, not because of low mood.
Ideas, concerns and expectations
- Idea: 'stress headaches from the case, and my blood pressure's up for the same reason'.
- Concern: her father's stroke (only if the doctor asks what worries her); losing the pill she relies on.
- Expectation: stronger painkillers and her pill re-issued today.
Cues to deliver, timed
- Minute 1: taps the desk — 'I really can't afford to be ill right now.'
- Minute 3: 'my dad had a stroke, so I do know about blood pressure' — said briskly.
- Minute 6: if told to stop the pill: 'and then what? I'm not getting pregnant.'
How to respond to the doctor's plan
- If the doctor explains three linked problems — probable medication-overuse headache on a background of migraine, a combined pill that must now stop because of blood pressure ≥160/100 (and migraine plus hypertension as risks), and hypertension that needs confirming — and offers a plan: stop the codeine and limit acute painkillers with warning about a temporary worsening, a migraine preventive later if needed, a bridging contraceptive today (progestogen-only pill, or discuss implant/IUS/IUD) with seven-day condom cover, ambulatory or home BP monitoring plus urine, bloods and ECG, lifestyle changes named specifically (alcohol, caffeine, sleep), red-flag safety-net, and review in two weeks: she is frustrated, then engages — 'so the tablets are causing the headaches?' and 'what's the quickest option for contraception?'.
- If the doctor gives stronger painkillers and re-issues the pill: thank them and leave; the examiner will not.
- If the doctor stops the pill without offering an alternative today: 'so you're leaving me with nothing?'.
Examination findings if requested
- BP today 162/100 (repeat 160/98); pulse 76 regular; BMI 24; fundi normal; no focal neurology; no papilloedema; heart sounds normal; no radio-femoral delay.
Do not
- Volunteer the true painkiller count, the father's stroke or the alcohol until asked.
- Report red-flag headache features; there are none.
Mark scheme
Delegates: open after your consultation. Examiner-observers: open during it.
Generic mark scheme — identical at every station
Domain grades
| Domain | CF (0) | F (1) | P (2) | CP (3) | Points |
|---|---|---|---|---|---|
| Data Gathering and Diagnosis | ☐ | ☐ | ☐ | ☐ | /3 |
| Clinical Management and Medical Complexity (×1.5) | ☐ | ☐ | ☐ | ☐ | /4.5 |
| Relating to Others | ☐ | ☐ | ☐ | ☐ | /3 |
| Total | /10.5 |
Global rating: ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass (CF Clear Fail · F Fail · P Pass · CP Clear Pass)
Feedback statement(s) — tick the one (at most two) you would attach
| Domain 1 | Domain 2 | Domain 3 |
|---|---|---|
| ☐ 1.1 Insufficient data | ☐ 2.1 Referral | ☐ 3.1 Cues / listening / formulaic |
| ☐ 1.2 Notes not used | ☐ 2.2 Prescribing | ☐ 3.2 Agenda / beliefs |
| ☐ 1.3 Psychosocial | ☐ 2.3 Investigations | ☐ 3.3 Circumstances / culture |
| ☐ 1.4 Unsystematic | ☐ 2.4 Prevention | ☐ 3.4 Explanations |
| ☐ 1.5 Prioritisation | ☐ 2.5 Risk management | ☐ 3.5 Judgemental |
| ☐ 1.6 Implications of findings | ☐ 2.6 Co-morbidity | ☐ 3.6 Respect / sensitivity |
| ☐ 1.7 Differentials | ☐ 2.7 Uncertainty | ☐ 3.7 Ownership |
| ☐ 1.8 Diagnosis / decision | ☐ 2.8 Follow-up / safety-net | ☐ 3.8 Teamwork |
| ☐ 2.9 Time management | ☐ 3.9 Safeguarding |
Timing checkpoints (Observer)
| Checkpoint (10-minute frame) | Done | Minute |
|---|---|---|
| Patient allowed to open without interruption (≈1 min) | ☐ | |
| ICE and psychosocial context elicited by 3:30 | ☐ | |
| Red flags covered; examination findings requested by 5:00 | ☐ | |
| Working diagnosis verbalised; gear change by 5:00–5:30 | ☐ | |
| Options shared; patient's preference used | ☐ | |
| Specific safety-net and follow-up by 9:30 | ☐ | |
| Understanding checked; finished inside 10:00 | ☐ |
Key points for this station — customised standard
Key points for this station
| Domain | Pass requires | Clear Pass adds | Fail if |
|---|---|---|---|
| Data Gathering & Diagnosis |
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| Clinical Management & Medical Complexity |
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| Relating to Others |
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Global rating guide: Pass = three problems recognised and prioritised, pill stopped with a bridge, medication-overuse headache managed, hypertension confirmed properly, safety-net.
Teaching points
- UKMEC: BP ≥160/100 is category 4 for combined hormonal contraception; migraine without aura is category 2, but with hypertension the combination is unwise; migraine with aura is category 4.
- NICE CG150 headaches: medication-overuse headache — analgesics or triptans on 10 or more days a month (simple analgesics 15 or more) for three months; stop abruptly; expect a worse month.
- NICE NG136: confirm with ABPM (or HBPM) before diagnosing; stage 2 (≥150/95 ABPM) treat; assess target-organ damage and QRISK at diagnosis.
Guidelines for this station
Your reflection
Record your grades, the statement attached, what you will keep and change, and your own reflection. Your entry is emailed to you as a record of this station; this page stays live so you can revisit the full case during revision.
Write my reflection for Station 3
Revision link for this case: mdacumen.com/sca-station3-headache
Editorial stamp · MRCGP SCA Consultation Skills Course · Station pages v1.0 · 11 September 2026 · Prof Rajesh Varma, Course Director · MD Acumen. Formative training material; not a prediction of exam performance. Not for onward distribution.