Cases/Neurology

Recurrent Daily Headaches Not Responding to Analgesia — Free SCA Practice Case

Man with recurrent daily headaches not responding to analgesia

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Simon Fletcher

Age

45 years

Consultation Type

Video

Age

45 (DOB: 12/09/1980)

Situation

Face-to-Face Consultation.

Reason for Encounter

"Patient complaining of daily headaches that have been worsening over the last three months. States that his usual over-the-counter painkillers are no longer working."

Medical Records

●PMH: Episodic tension-type headaches (historically 1-2 per month), Mild Hypertension.
●Medications: Ramipril 2.5mg OD.
●Allergies: NKDA.

Recent Notes

●No recent attendances. Last BP check 6 months ago was normal (128/82).

Patient Script

For the friend playing the patient role

Character Overview: You are Simon, a 45-year-old architect. You are highly stressed, exhausted, and in constant, nagging pain. For the last three months, you have woken up almost every single day with a dull, heavy headache pressing on both sides of your head. To cope and keep working, you started taking painkillers. It began with just a few paracetamol. Now, you are taking over-the-counter Co-codamol (paracetamol and codeine) and Ibuprofen almost every single day, often multiple times a day. You don't realize that the painkillers are actually causing the daily headaches. You are secretly terrified because a senior partner at your firm died of a brain tumour (glioblastoma) last year, and his symptoms started with "a headache that wouldn't go away." You want a brain scan and stronger painkillers. You will not volunteer your fear of a brain tumour or the sheer volume of pills you are taking unless the doctor specifically asks you to quantify your medication use or explores your underlying worries.

Consultation Flow & Responses:

●
The Opening
●
If the doctor asks an open question: "Morning, Doctor. I really need your help, or ideally a referral for an MRI scan. I've had a headache every single day for the last three months. The paracetamol and ibuprofen I buy at the pharmacy aren't touching it anymore, and I can't concentrate at work."
●
Data Gathering (The Layers)
●
Layer 1: Headache Characteristics & Red Flag Screen:
●
"It's a dull, tight, squeezing pain on both sides of my head. Like a tight band."
●
"It's there the minute I wake up in the morning."
●
"No, I haven't been sick (vomiting). No changes to my vision, my speech is fine, and my arms and legs feel normal." (Rules out raised ICP / space-occupying lesion).
●
"It doesn't wake me up from sleep, but it's there as soon as I open my eyes."
●
Layer 2: The Medication Trap (The Core Clinical Clue):
●
If asked exactly WHAT and HOW OFTEN he is taking: "Well, because it hurts every day, I take painkillers every day. Usually, two Co-codamol when I wake up, maybe some Ibuprofen at lunch, and another two Co-codamol in the evening. I've been doing that for at least two months just to get through the workday."
●
Layer 3: Triggers & Stress:
●
"Work is incredibly stressful right now, yes. Lots of deadlines. But I've been stressed before and never had headaches every single day like this."
●
Layer 4: ICE & The Core Revelation (The Hidden Fear) - ONLY REVEAL IF ASKED:
●
If the doctor asks: "What are you worried is causing this?" or "Why did you specifically mention wanting an MRI today?"
●
Reaction (The Reveal): You look incredibly anxious and drop your voice. "A partner at my architecture firm died last year. Brain cancer. He kept complaining of a headache that wouldn't clear up, and by the time they scanned him, it was too late. I have exactly the same thing. It's constant. I just need you to scan me to prove I don't have a tumour."

ICE — Ideas, Concerns, Expectations

(Actor guidance: Do not volunteer any of this unprompted. These responses surface only when the candidate directly explores the patient's perspective. The fear of a brain tumour is already scripted in Layer 4 above — if the candidate has already unlocked that reveal, do not repeat it mechanically here; let the conversation flow naturally.)

●
Ideas: You have no real medical explanation for why the headaches started — you just know they appeared and got worse. In the back of your mind, the only 'explanation' you have is the terrifying one: your colleague had the same thing and it turned out to be cancer. You don't think stress alone could cause something this relentless. If asked directly what you think is going on: "Honestly? I don't know. I just know it's not normal to have a headache every single day. I keep thinking about what happened to David at work."
●
Concerns: Your deepest fear is that you have a brain tumour. Beyond that, you are worried about: (1) not being able to function at work — you are leading a major project and cannot afford to be off; (2) the painkillers not working anymore and having nothing left to fall back on; (3) something being seriously wrong that is being missed. If asked: "I'm scared it's something serious. And even if it isn't, I can't keep going like this — I'm barely getting through the day."
●
Expectations: You came in wanting two things: an MRI scan to rule out a brain tumour, and stronger painkillers because the ones you buy aren't working. You would accept an alternative plan if the doctor can clearly explain why a scan isn't needed right now and offers a credible path to getting rid of the headaches. If asked: "I want a scan — I need to know it's not what David had. And I need something stronger, because what I'm taking isn't doing anything anymore."

If Asked — Medical History and Medications

(Actor guidance: Respond naturally if the candidate asks about your past medical history, current medications, or previous GP visits. Do not volunteer this information unprompted.)

●
If asked about previous headaches / history of headaches: "Yeah, I've had headaches on and off for years — tension headaches, the GP said. Maybe once or twice a month, usually when I was under pressure. A couple of paracetamol would sort them out and I'd get on with it. But this is completely different — it's every single day now and nothing shifts it."
●
If asked about blood pressure / hypertension: "The doctor told me my blood pressure was a bit high a while back — nothing dramatic, just slightly raised. I'm on a tablet for it. I take it every morning."
●
If asked what blood pressure tablet / about Ramipril: "Ramipril, I think it's called. A low dose — 2.5mg. I've been on it for a couple of years. No problems with it."
●
If asked about allergies: "No, no allergies to anything that I know of."
●
If asked about recent GP visits: "I haven't been to the GP in months. My last visit was just a routine blood pressure check about six months ago — the nurse said it was fine."

Social History and Lifestyle Impact

(Actor guidance: This context should emerge naturally in conversation, particularly when discussing triggers, stress, or the impact of the headaches. Do not deliver it as a monologue.)

●
Occupation and daily life: You are a senior architect at a mid-sized practice. You spend long hours at a screen — detailed technical drawings, planning applications, client presentations. The work requires intense concentration. You are currently project lead on a large mixed-use development that is behind schedule, with a planning submission deadline in six weeks.
●
Family situation: You live with your wife and two children (aged 10 and 13). Your wife works part-time. You are the main earner.
●
Lifestyle impact of the condition: The headaches are destroying your ability to do your job. You used to be able to sit at your workstation for hours; now you lose focus after 30 to 40 minutes because the pain creeps up and you can't think clearly. You have started making mistakes on drawings that your junior colleagues have had to catch, which is embarrassing and professionally dangerous. You are staying late most evenings to redo work, which means you are getting home after the children are in bed. Your wife has noticed you are irritable and withdrawn — you had an argument last week because she said you were "not present" even when you were home. You are drinking two to three strong coffees in the morning to push through the pain and fatigue, and you have cut out the gym entirely because the exertion makes the headache worse. If asked: "I'm making mistakes at work that I never used to make. I had to redo a full set of elevations last week because I'd missed a setback error — my junior picked it up before it went to the client, but that's never happened to me before. I'm staying late every night and I'm barely seeing my kids. My wife thinks I'm shutting her out but I'm just in pain and exhausted."

If Asked — Associated Symptoms

(Actor guidance: Respond only if the candidate specifically asks about these symptoms. Keep answers brief and natural.)

●
If asked about neck pain or stiffness: "My neck and shoulders are stiff, yeah — they have been for weeks. I put it down to hunching over my desk all day."
●
If asked about sensitivity to light (photophobia): "Not really, no. Bright light doesn't bother me particularly."
●
If asked about sensitivity to noise (phonophobia): "No, noise doesn't make it worse."
●
If asked about aura or visual disturbance before the headache: "No, nothing like that. No flashing lights or zigzag lines. It's just there constantly."
●
If asked about nausea: "I feel a bit rough sometimes, but I haven't actually been sick."
●
If asked about fever or feeling unwell: "No, no fever. I don't feel ill as such — just this constant headache and being knackered."
●
If asked about weight loss: "No, my weight's been about the same. If anything I've put on a few pounds because I've stopped exercising."
●
If asked about jaw pain or pain on chewing (jaw claudication): "No, nothing like that."
●
If asked about scalp tenderness: "No, my scalp feels normal."
●
If asked about eye pain or changes in vision: "No, my eyes are fine. I had them tested about a year ago and they were normal."
●
If asked about seizures or fits: "No, never had a fit or anything like that."
●
If asked about confusion or memory problems: "I wouldn't say confusion exactly, but my concentration is shot. I can't focus the way I used to. I put that down to the pain though."
●
If asked about any weakness, numbness, or tingling: "No, nothing like that. Arms and legs feel completely normal."
●
If asked about sleep: "I'm sleeping, but I don't wake up feeling rested. I'm exhausted all the time. I think I'm sleeping about five or six hours — I lie awake worrying and then the alarm goes off and the headache is already there."
●
If asked about mood / depression / anxiety: "I wouldn't say I'm depressed, but I'm definitely not myself. I'm anxious all the time — anxious about the headache, anxious about work, anxious about what this might be. It's like a constant background hum of dread."
●
If asked about caffeine intake: "I drink a lot of coffee — probably three or four strong ones before lunch. I need it to get going because the headache and tiredness are so bad in the morning."
●
If asked about alcohol: "I'll have a glass of wine or a beer in the evening sometimes. Maybe two or three times a week. Nothing excessive."
●
If asked about smoking: "No, I've never smoked."
●
If asked about recreational drugs: "No, nothing like that."

Negotiation & Collaborative Management Plan

●
If the Doctor prescribes stronger painkillers (e.g., Codeine/Tramadol):
●
Reaction: "Thank you. Will these finally kill the pain?" (Note: Candidate critically fails for worsening a Medication Overuse Headache and feeding opiate dependence).
●
If the Doctor completely dismisses the tumour fear without examining you:
●
Reaction: Defensive. "How can you be so sure without a scan? You're just guessing! That's exactly what my colleague's doctor did!" (Testing the doctor's ability to explain clinical reasoning).
●
If the Doctor diagnoses Medication Overuse Headache (MOH) and says to stop all pills abruptly:
●
Reaction: Shocked and resistant. "Stop taking them?! But I'm in agony with them! If I stop, my head will explode and I'll have to take time off work. I can't do that!"
●
If the Doctor explains the "Rebound" mechanism and validates the pain:
●
Reaction: Skeptical but listening. "So you're saying my brain has become addicted to the painkillers, and the headache is actually a withdrawal symptom? How long will it take to clear if I stop?"

Safety Netting / Follow-up

●If the Doctor warns about the withdrawal period and books a follow-up:
●Reaction: "Okay. You're saying it's going to get much worse for a week or two before it gets better. I'll ask to work from home next week to get through it. I'll see you in a month."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 2: Clinical Management and Medical Complexity

0 / 28 indicators checked+0−0

Positive (0/14)

Negative (0/14)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

Recognising Medication Overuse Headache — The Diagnostic Shift

The transformation from episodic to daily headache is the cardinal signal of Medication Overuse Headache (MOH). When a patient with a known primary headache disorder (tension-type or migraine) reports that their headache has become daily or near-daily and their usual analgesia is no longer effective, MOH must be the leading diagnosis until proven otherwise.

●NICE CKS diagnostic criteria: Headache on ≥15 days per month, with regular overuse of acute analgesia for >3 months. The threshold differs by drug class: simple analgesics (paracetamol, NSAIDs, aspirin) on ≥15 days/month; opioids, triptans, or combination analgesics (including co-codamol) on ≥10 days/month.
●The morning headache pattern — present on waking but not waking from sleep — is characteristic of MOH. It reflects overnight analgesic withdrawal as plasma levels fall. This is a critical distinguishing feature from raised intracranial pressure, where headaches typically worsen on coughing, straining, or lying flat and may wake the patient from sleep.
●Quantify medication use precisely. Accepting "I take painkillers every day" without establishing the specific agents, frequency, and number of days per month is the single most common way this diagnosis is missed. Co-codamol contains codeine — an opioid — placing it in the 10-days/month threshold category.

Red Flag Exclusion Before Diagnosing MOH

A clinical diagnosis of MOH requires confident exclusion of secondary headache causes. In a 45-year-old presenting with a three-month history of daily headache, the following must be screened for:

●Features of raised intracranial pressure / space-occupying lesion: Thunderclap onset, progressive worsening over weeks, headache that wakes from sleep, postural exacerbation (worse bending/straining/coughing), morning vomiting, new focal neurological deficit, personality change, new seizures, papilloedema on fundoscopy.
●Giant cell arteritis (GCA): Always consider in patients over 50; less relevant here at 45 but worth noting given jaw claudication, scalp tenderness, and temporal artery tenderness are specific red flags. NICE CKS recommends urgent same-day ESR, CRP, and specialist referral if GCA is suspected.
●Meningism: Fever, photophobia, neck stiffness, non-blanching rash.
●Idiopathic intracranial hypertension: More common in overweight women of reproductive age, but BMI and visual symptoms should still be noted.
●Simon has none of these features. A normal neurological examination and fundoscopy, in the context of a bilateral pressure headache with no red flags, provides a robust clinical basis for reassurance and safe refusal of MRI.

The Ibuprofen–Ramipril Interaction — A Prescribing Safety Priority

Daily NSAID use in a patient taking an ACE inhibitor is a clinically significant drug interaction that must be identified and addressed explicitly.

●Mechanism: NSAIDs inhibit prostaglandin-mediated afferent arteriolar dilation in the kidney, reducing renal perfusion pressure. In combination with an ACE inhibitor (which reduces efferent arteriolar tone), this creates the "triple whammy" risk — particularly under volume depletion — leading to acute kidney injury.
●Antihypertensive antagonism: Regular ibuprofen blunts the antihypertensive effect of ramipril, potentially contributing to uncontrolled blood pressure in a patient with established hypertension.
●Clinical action: Cessation of ibuprofen as part of MOH withdrawal resolves both the renal and antihypertensive concerns simultaneously. This should be framed explicitly — stopping the ibuprofen is not only the correct headache treatment, it is also protecting his kidneys and blood pressure.
●BP check is mandatory: Simon's last blood pressure was six months ago, and he has been taking daily NSAIDs for at least two months on a background of hypertension managed with ramipril. A blood pressure reading at this consultation is a clinical necessity.

Management of MOH — The Withdrawal Strategy

The mainstay of treatment is complete withdrawal of all overused acute headache medications. This is strongly supported by NICE CKS.

●Abrupt cessation is the recommended approach for simple analgesics, NSAIDs, and low-to-moderate dose opioid-containing combination analgesics such as co-codamol. Gradual tapering is generally reserved for high-dose prescription opioids or prolonged benzodiazepine use.
●Warn patients explicitly about the withdrawal period. Headaches will worsen significantly for 1–2 weeks before improving. This is not treatment failure — it is the expected and necessary withdrawal process. Patients who are not warned almost universally relapse at this point.
●Codeine-specific withdrawal: Co-codamol contains codeine, and physical dependence can develop with regular use over weeks to months. Simon should be counselled that in addition to worsening headache, he may experience sweating, restlessness, agitation, and insomnia during the first week of withdrawal. These are codeine withdrawal symptoms, not signs of a serious illness.
●Caffeine reduction must be managed alongside analgesia withdrawal. Simon is consuming 3–4 strong coffees daily. High caffeine intake is both a headache trigger and a perpetuating factor in the MOH cycle. Abrupt caffeine cessation independently causes headaches; the recommended approach is gradual reduction (e.g., reduce by one cup every few days) concurrent with analgesic withdrawal, rather than stopping all at once.
●Do not prescribe stronger analgesia. Escalating to tramadol or prescription opioids in response to a patient reporting that their current analgesia is "no longer working" in the context of MOH will deepen dependence and entrench the cycle. This is one of the most consequential prescribing errors in this presentation.

Preventive Therapy — Timing Matters

Preventive medications are ineffective while medication overuse is ongoing and should not be initiated until the withdrawal period is complete and the baseline headache phenotype has re-established itself.

●Why timing matters: Central sensitisation from overuse blunts the response to prophylactic agents. Initiating amitriptyline or propranolol during active overuse is associated with treatment failure and may inappropriately label the patient as refractory.
●After successful withdrawal: Reassess the headache type at the 3–4 week follow-up. If the underlying disorder is tension-type headache, low-dose amitriptyline is first-line for prevention. If the phenotype is migrainous, propranolol or topiramate are first-line options per NICE CKS.
●The follow-up appointment must be proactive and structured — not "come back if it doesn't get better." The purposes are: confirm withdrawal success, identify the baseline phenotype, decide on prophylaxis, and assess whether MRI referral is then warranted.

Addressing the MRI Request — Clinical Reasoning, Not Dismissal

Refusing a patient's request for investigation requires transparent reasoning, not assertion.

●The clinical rationale for declining MRI rests on three pillars: (1) a clear alternative diagnosis (MOH) that fully explains the symptom pattern; (2) a normal focused neurological examination including fundoscopy; (3) the absence of red flag features. These three together constitute a robust and defensible clinical decision.
●Offer a conditional pathway: If daily headaches persist after successful analgesic withdrawal, MRI should be reconsidered. This reframes the refusal as a clinical sequencing decision rather than a closed door, and gives the patient a sense of agency.
●Never refuse an MRI without examining the patient. A clinical decision not to refer for imaging is only defensible after a documented neurological examination. Examination also provides objective reassurance to a patient with significant health anxiety.

Safety Netting and Structured Follow-up

●Red flags during the withdrawal period requiring urgent reassessment: thunderclap headache (sudden severe onset), new neurological symptoms (limb weakness, speech disturbance, visual loss), fever with headache, or significant cognitive change. Simon should be told to seek emergency care if any of these develop.
●Routine follow-up at 3–4 weeks to assess withdrawal success, re-evaluate the headache phenotype, consider preventive therapy, and review blood pressure.
●Written information: The Migraine Trust (www.migrainetrust.org) provides patient-facing resources on MOH and the withdrawal process. Providing written information significantly improves adherence during the withdrawal period, when pain and doubt are at their peak.
●Occupational support: Acknowledge that the withdrawal period is functionally disabling. A short Fit Note (1–2 weeks) or documented discussion of working from home is appropriate and demonstrates recognition of Simon's wider context. Brief signposting to IAPT for occupational anxiety is worthwhile if the patient is receptive.

Free MRCGP SCA practice case for GP registrars covering Recurrent Daily Headaches Not Responding to Analgesia — Neurology. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

← Back to Free SCA Practice Cases