New Severe Headache — Free SCA Practice Case

Character Overview: You are Anisha, 28 and 32 weeks pregnant with your first baby. For the past three days you have had a persistent frontal, throbbing headache, with blurred vision and flashing lights. You also have a dull ache under your ribs on the right side of your tummy. You feel nauseated but have not vomited. Paracetamol has not helped at all. You checked your blood pressure on a home machine and it read 150/90. You are at home with your husband. Your elder sister had high blood pressure in pregnancy (mention only if asked). You have had migraines occasionally in the past and you assume this is one, but you were told not to take anything except paracetamol in pregnancy — so you are ringing to ask for something stronger, perhaps codeine or a migraine tablet. You are not especially alarmed and will initially be reluctant to go anywhere today.

Opening Sentence: "Hi Doctor. I've had this headache for three days now — it's right across the front of my head and throbbing. Paracetamol's doing nothing. I'm 32 weeks pregnant so I know I can't take much, but is there something stronger you can give me? I think it's one of my migraines."

History if Asked (Data Gathering Phase)

• ●The headache: "Three days, frontal, throbbing, constant really. It's not easing off at all."
• ●Vision: "My vision's been blurred, and I keep seeing flashing lights."
• ●Abdominal discomfort: "There's a dull ache under my ribs on the right side. I assumed it was the baby pressing on something."
• ●Nausea: "I feel sick but I haven't actually been sick."
• ●Paracetamol: "I've been taking it regularly and it's made no difference whatsoever."
• ●Blood pressure: "I checked on my mum's machine at home — it said 150 over 90."
• ●What she wants: "Something stronger for the pain. Codeine, or one of those migraine tablets?"

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

• ●Ideas: Anisha believes this is a migraine. "I've had migraines before — I assume it's one of those."
• ●Concerns: Her stated concern is the pain and not being able to take anything in pregnancy; she has not connected the symptoms with anything serious. "I'm just worried about the pain and what's safe to take while I'm pregnant."
• ●Expectations: She expects stronger analgesia. "I want something that'll actually work."

If Asked — Pre-eclampsia, Fetal, and Differential Screen

The patient answers these only when directly asked.

• ●If asked about visual disturbance in detail: "Blurred vision, and flashing lights in front of my eyes. It's been happening for a couple of days."
• ●If asked about epigastric or right upper quadrant pain — key: "Yes — a dull ache under my ribs on the right. It's been there a day or two."
• ●If asked about swelling of the face, hands, or feet: "My hands and face have felt puffy, actually. My rings are tight."
• ●If asked about home blood-pressure readings: "150 over 90 this morning."
• ●If asked about fetal movements — essential: "The baby's been moving, yes — I think about the same as usual."
• ●If asked about vaginal bleeding, fluid loss, or discharge: "No bleeding, no waters, nothing like that."
• ●If asked about contractions or abdominal tightening: "No contractions."
• ●If asked about weakness, slurred speech, seizures, or abnormal movements: "No weakness, no speech problems, no fits."
• ●If asked about neck stiffness, fever, or rash: "No fever, no stiff neck, no rash."
• ●If asked about whether this is like her usual migraines: "Now you ask… not really. My migraines are usually one-sided and they settle with paracetamol and a dark room. This is different — it's not shifting at all."
• ●If asked about family history — pre-eclampsia or hypertension in pregnancy: "My older sister had high blood pressure when she was pregnant, yes."
• ●If asked about risk factors (first pregnancy, age, BMI, diabetes, kidney or autoimmune disease, IVF, multiple pregnancy): "It's my first baby. No diabetes, no kidney problems, nothing autoimmune. Single baby, conceived naturally."
• ●If asked about who is with her and how she would travel: "My husband's here and he can drive me."

Responses to Management (The Negotiation Phase)

• ●If the Doctor explains this may be pre-eclampsia rather than migraine — key: "Pre-eclampsia? I thought that was just about blood pressure — I didn't realise a headache could be part of it." (The tested point is recognising pre-eclampsia and explaining it, rather than treating the migraine label.)
• ●If the Doctor declines stronger analgesia and explains why: "So stronger painkillers would just mask it? That makes sense when you put it like that." (The tested point is declining inappropriate analgesia with a clear rationale.)
• ●If the Doctor arranges same-day maternity assessment — the negotiation: "Today? I've got things on, and I've got a midwife appointment next week anyway. Can it not wait until then?" (The tested point is converting this into same-day obstetric assessment and holding firm.)
• ●If the Doctor explains what will happen at the unit: "So they'll check my blood pressure, test my urine, do bloods and check the baby? Alright."
• ●If the Doctor advises not to drive: "I shouldn't drive myself? My husband can take me, that's fine."
• ●If the Doctor safety-nets: "And if the headache gets much worse on the way, or my vision goes, I ring 999. Understood."