Summary of Common Conditions for OSCEs
| Condition | Key points | Key investigations |
| Migraine | Nausea, vomiting Photophobia Periodic (e.g. every month), correlation with menstrual periods Visual disturbance (zigzag lines, flashing lights) Aura | None – clinical diagnosis |
| Tension headaches | ‘Tight’ headache Diffuse, not localised Related to stress | None – clinical diagnosis |
| Meningitis | Fever Photophobia Neck stiffness Haemorrhagic rash | Lumbar puncture and cerebrospinal fluid analysis Microscopy, culture and sensitivity on blood sample |
| Trigeminal neuralgia | Like ‘electric shock’ Short duration (seconds to a few minutes) Face/in front of ear Chewing makes it worse | Could consider electrophysiological studies Largely a clinical diagnosis |
| Chronic analgesia overuse headaches | Long-term extensive use of high-dose analgesics Daily occurrence No ‘red flags’ | None – clinical diagnosis |
| Cluster headaches | Pain around one eye Lacrimation/eye watering Excruciatingly severe Attacks of 30–60 minutes persist for a few weeks to 1–2 months and then stop for 6–12 months | None – clinical diagnosis |
| Intracerebral haemorrhage | Recent trauma Features of raised ICP Subdural haemorrhage:
| CT/MRI brain |
| Subarachnoid haemorrhage | Sudden onset (like being hit on the head with a cricket bat) Occipital ‘Worst’ pain the patient has ever had | Lumbar puncture and cerebrospinal fluid analysis CT brain |
| Increased intracranial pressure | Nausea, vomiting (increased intracranial pressure) Worse on straining/bending down/coughing Focal neurological signs History of malignancy | CT/MRI brain |
| Temporal arteritis | Scalp tenderness Ipsilateral visual disturbance Shoulder/hip muscle aches (polymyalgia rheumatica) | Temporal artery biopsy Erythrocyte sedimentation rate |
| Sinusitis | Pain and tenderness around temples/sinuses Recent upper respiratory tract infection | None – clinical diagnosis |
| Referred pain | Pain in teeth or temporomandibular joint | None – clinical diagnosis Rule out other causes |
Hints and Tips for the Exam
Headaches are a very common presentation in both primary and secondary care settings. The history may be very vague, and unless you ask all the relevant questions you may miss a serious cause, especially with children and forgetful elderly patients. The importance of meticulously working through the acronyms and red flags cannot be underestimated.
Combined Oral Contraceptive Pill and Migraines
Always ask a woman with suspected migraines if she is taking the combined oral contraceptive pill as it may well be contraindicated, especially if she suffers from auras or focal neurological symptoms. If you are not sure, it is reasonable to tell the patient that you will check and get back to her, and to advise her to withhold the pill and use barrier contraception in the interim.
Don’t Forget Trauma
Trauma is often forgotten by students, but is vitally important. A chronic subdural haemorrhage can present days after the initial trauma in alcoholics and elderly patients.
Questions You Could Be Asked
Q. What are the cerebrospinal fluid findings after a subarachnoid haemorrhage?
A. Xanthochromia (4–5 hours after the episode), red blood cells and bilirubin.
Q. Give a non-bacterial cause of meningitis.
A. A fungal cause is Cryptococcus. Viral causes are Epstein–Barr virus, mumps, enterovirus and herpes virus.
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