Cases/Ear, Nose and Throat

Shooting Jaw Pain — Free SCA Practice Case

Older woman with shooting jaw pain

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

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Brenda Higgins

Age

72 years

Consultation Type

Video

Age

Reason for Encounter

"Severe face pain. Think it's a toothache but dentist sent me to you."

Medical Records

●PMH: Hypertension, Osteoarthritis (hips).
●Medications: Amlodipine 5mg OD. Paracetamol PRN.
●Allergies: NKDA.

Recent Notes

●3 Days Ago: Emergency dentist appointment. Examination and X-ray normal. No dental abscess found. Advised to see GP for "nerve pain."

Patient Script

For the friend playing the patient role

Character Overview: You are Brenda. You are in agony, but you are terrified to move your mouth. You speak with a "still" jaw (mumbling) because you are scared that opening your mouth wide will trigger the pain. You are exhausted and haven't eaten properly in 3 days.

Opening Sentence: (Holding hand near, but not touching, left jaw) "Doctor, it's agony. It's like being struck by lightning right here (points to lower left jaw). The dentist said my teeth are fine, but I can't eat, I can't sleep. Please stop it."

History if Asked (Data Gathering Phase)

●
The Pain (Classic Trigeminal Neuralgia):
- ●Nature: "Electric shocks." "Stabbing." "Like a hot poker."
- ●Duration: "It only lasts seconds, maybe a minute, but it leaves me shaking."
- ●Frequency: "It happens 20 or 30 times a day."
- ●Triggers: "If the wind hits my face... brushing my teeth... trying to eat toast. Even you talking to me is making me nervous."
●
Red Flags (Ruling out GCA/Tumour):
- ●Vision: "My eyesight is fine."
- ●Scalp Tenderness: "No pain when brushing my hair, only when touching my face."
- ●Systemic: "I've lost a bit of weight this week because I'm scared to eat." No fever or night sweats.
- ●Between Attacks: "It's fine. No ache. Just the fear of the next one."
●
Current Management:
- ●"I've taken Paracetamol and Ibuprofen. They are like tic-tacs. They do nothing."

ICE — Ideas, Concerns, Expectations

(Only if the candidate directly explores the patient's perspective — do not volunteer unprompted.)

●Ideas: "The dentist said it might be nerve pain. I just know it's not my teeth because the dentist checked everything."
●Concerns: "I'm terrified it's going to be like this forever. I can't live like this — I can't eat, I can't talk to my grandchildren properly, I'm frightened to leave the house in case the wind sets it off. And at my age, you do worry... the dentist mentioned 'nerve pain' and I keep thinking, what if it's something more serious?"
●Expectations: "I just need something that will stop these shocks. I don't care what it is — tablets, injections, anything. I need to be able to eat and sleep again. And I need to know what's actually causing it."

If Asked — Medical History and Medications

(Actor guidance — respond naturally if the candidate asks about past medical history or current medications.)

●Hypertension / Amlodipine: "Yes, I take a blood pressure tablet — amlodipine, the little white one. I've been on that for years. I take it every morning, never miss it. My blood pressure has been fine at my check-ups."
●Osteoarthritis (hips): "I've got arthritis in both hips — some days worse than others. I take paracetamol when it's bad, but to be honest this face pain has made me forget all about my hips. This is on a completely different level."
●Paracetamol use: "I've been taking it round the clock for this face pain — four times a day — and it hasn't touched it. Normally it takes the edge off my hip pain, but for this? Nothing."
●Ibuprofen: "I bought some ibuprofen from the chemist as well. Same thing — no difference at all."
●Allergies: "No, no allergies to anything that I know of."
●Dentist visit: "I went to the emergency dentist three days ago because I was convinced it was a tooth. They did an X-ray and everything — said my teeth were perfect. The dentist said it sounded like nerve pain and told me to come and see you."

Social History and Lifestyle Impact

(Actor guidance — volunteered naturally in conversation, not as a monologue.)

●Occupation / daily life: Brenda is retired. She lives with her husband, Derek (75), in their own home. She is normally an active, independent woman — does the shopping, the cooking, looks after their two grandchildren (aged 5 and 7) every Wednesday afternoon while her daughter is at work. She volunteers at the local charity shop on Fridays.
●Lifestyle impact of the condition: "I haven't been able to eat properly for three days — I'm living on lukewarm soup through a straw because chewing sets it off. I cancelled having the grandchildren on Wednesday because I couldn't face it — I was terrified one of them would touch my face or I'd have an attack in front of them and scare them. I haven't left the house since the dentist because the cold air is a trigger. Derek is having to do everything — the shopping, the cooking — and he's not well himself. I feel like I've gone from being the one who holds everything together to being completely useless in three days."

If Asked — Associated Symptoms

(Actor guidance — respond only if directly asked by the candidate.)

●If asked about pain on both sides of the face: "No, it's only ever on this side — the left. Always the same spot."
●If asked about numbness or tingling in the face: "No, I can feel everything normally. It's not numb — it's the opposite, it's too sensitive."
●If asked about weakness in the face or drooping: "No, nothing like that. My face looks normal in the mirror — it just doesn't feel normal."
●If asked about hearing changes or tinnitus: "No, my hearing is fine."
●If asked about difficulty swallowing: "No, I can swallow fine — it's the chewing that sets it off."
●If asked about headaches: "No, I don't get headaches. This isn't a headache — it's like a bolt of electricity."
●If asked about jaw clicking or locking: "No, the jaw itself is fine. The dentist checked all that."
●If asked about eye pain, redness, or watering: "No, my eyes are fine."
●If asked about any rash or blisters on the face: "No, nothing like that. The skin looks completely normal."
●If asked about earache: "No earache, no."
●If asked about neck stiffness or pain: "No, my neck is fine."
●If asked about dizziness or balance problems: "No, nothing like that."
●If asked about any previous episodes like this: "Never. This is the first time anything like this has ever happened."
●If asked about recent infections or cold sores: "No, I haven't been unwell at all before this started."
●If asked about stress or low mood: "I wouldn't say I was stressed before this, but I'm certainly low now. I've been in tears every day. I just feel desperate."

Responses to Management (The Negotiation Phase)

●
If the Doctor prescribes Carbamazepine:
- ●Reaction: "Will it work straight away? I can't go another night like this." (Doctor needs to explain titration).
●
If the Doctor suggests strong painkillers (Codeine/Morphine):
- ●Reaction: "I tried my husband's Co-codamol yesterday. It just made me sick and didn't stop the shocks. Are you sure that's the right thing?"
●
If the Doctor discusses MRI:
- ●Reaction: Worried. "A brain scan? Do you think I have a tumour?"
●
If the Doctor mentions driving:
- ●Reaction: "I can't drive anyway with this pain, but does the medicine make me drowsy?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 2: Clinical Management and Medical Complexity

0 / 32 indicators checked+0−0

Positive (0/16)

Negative (0/16)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

Diagnosing Trigeminal Neuralgia: The Pathognomonic Features

●Trigeminal neuralgia (TN) is diagnosed clinically. The hallmark features are: strictly unilateral facial pain of electric shock or stabbing quality, lasting seconds to under two minutes, occurring in bursts of up to 20–30 attacks per day, with complete pain freedom between attacks.
●Trigger identification is central to the diagnosis — common triggers include light touch to specific facial zones, cold air/wind, eating, tooth brushing, and talking. The presence of trigger zones strongly supports classic TN.
●Pain-free intervals are a key discriminating feature: if there is any background ache between attacks, consider an alternative or secondary diagnosis (e.g., persistent idiopathic facial pain, secondary TN from a structural cause).
●Distribution: Pain most commonly affects V2 (maxillary) or V3 (mandibular) divisions. Unilateral V1 (ophthalmic) involvement is rare in classic TN and should prompt further investigation.

Red Flags for Secondary Trigeminal Neuralgia

●
The following features suggest a secondary cause (e.g., space-occupying lesion, demyelination, vascular malformation) and require urgent investigation:
- ●Facial numbness or sensory loss — the single most important red flag
- ●Facial weakness or drooping
- ●Bilateral symptoms
- ●Age under 40 — raises suspicion for multiple sclerosis
- ●Continuous background pain between attacks
- ●Hearing changes or tinnitus — suggests posterior fossa pathology
●A secondary cause must be excluded before attributing symptoms to classic TN, particularly in younger patients or those with atypical features.

Distinguishing TN from Giant Cell Arteritis (GCA)

●GCA must be considered in any patient over 50 presenting with new head or face pain — it is a sight-threatening emergency.
●
Key distinguishing features:
- ●TN: Electric shock pain lasting seconds, triggered by light touch or cold air, with pain-free intervals
- ●GCA: Jaw claudication (a dull ache or fatigue on sustained chewing due to muscle ischaemia — not triggered by light touch), scalp tenderness on combing/washing, new headache, visual disturbance (amaurosis fugax, diplopia, or sudden visual loss), and systemic features (fever, malaise, elevated ESR/CRP)
●Always document that you specifically asked about scalp tenderness and visual symptoms in any patient over 50 presenting with facial or head pain.

First-Line Pharmacotherapy: Carbamazepine

●Carbamazepine is the evidence-based first-line treatment for TN (NICE CKS). It is a sodium channel blocker and reduces aberrant nerve firing — it is not prescribed for pain in the conventional analgesic sense.
●Standard analgesics (paracetamol, NSAIDs, opioids) are ineffective for TN. If a patient reports these have not helped, this is clinically consistent with the diagnosis and should not prompt further analgesic escalation.
●Starting dose: 100mg twice daily. Titrate slowly every few days — typically by 100–200mg increments — until pain freedom is achieved or tolerability is reached. Therapeutic range is usually 400–1200mg/day.
●Explain to the patient that the medication requires titration and may take several days to reach a fully effective dose. Setting this expectation reduces premature abandonment of treatment.

Carbamazepine: Monitoring and Adverse Effects

●Common side effects: Drowsiness, dizziness, unsteadiness (ataxia), and nausea — particularly during titration. These often improve as the body adjusts, but are important to counsel on.
●Serious adverse reaction — Stevens-Johnson Syndrome (SJS): Warn the patient explicitly to seek immediate medical attention if they develop a widespread rash, skin blistering, mouth ulcers, or fever after starting carbamazepine. SJS is rare but potentially life-threatening.
●
Baseline and monitoring bloods should be arranged before or shortly after starting:
- ●FBC — risk of agranulocytosis and leucopenia (rare but serious)
- ●U&Es — risk of hyponatraemia (SIADH-like effect; clinically significant, especially in elderly patients)
- ●LFTs — risk of hepatotoxicity
●Recheck bloods at 6 months and annually once stable, or sooner if symptoms suggest toxicity.

Drug Interaction: Carbamazepine and Amlodipine

●Carbamazepine is a potent inducer of CYP3A4, the hepatic enzyme responsible for metabolising many common drugs.
●Amlodipine (a calcium channel blocker) is a CYP3A4 substrate — carbamazepine induction can significantly reduce plasma amlodipine levels, potentially leading to loss of antihypertensive effect and worsening blood pressure control.
●In any patient established on amlodipine, arrange more frequent blood pressure monitoring after starting carbamazepine and be prepared to consider dose adjustment.
●Other clinically important interactions: combined oral contraceptive pill (reduced efficacy), warfarin (reduced anticoagulation), and statins (reduced efficacy). Check the full interaction profile for any patient on polypharmacy.

Second-Line and Escalation Options

●If carbamazepine is not tolerated or fails to achieve adequate pain control, oxcarbazepine is the preferred alternative — better tolerated than carbamazepine with a similar mechanism of action. It is used off-label in the UK for TN.
●Other agents used in refractory cases (usually under neurology or pain specialist supervision): lamotrigine, baclofen, gabapentin.
●Surgical options exist for medically refractory TN — including microvascular decompression (MVD), stereotactic radiosurgery (Gamma Knife), and percutaneous procedures — but these are neurosurgical decisions made in secondary care.

Imaging: When to Request MRI

●
MRI brain (with trigeminal nerve protocol) is indicated in the following situations (NICE CKS):
- ●Age under 40 (screen for MS and structural lesions)
- ●Atypical features: sensory loss, facial weakness, hearing change, continuous pain, bilateral symptoms
- ●Failure to respond to appropriate first-line treatment after adequate titration
- ●When neurosurgical referral is being considered
●Routine immediate MRI is not mandated in a patient over 40 with a classic, typical presentation who responds well to carbamazepine — vascular compression (the underlying cause in most classic TN) may be seen but is often an incidental finding that does not change initial management.
●When discussing MRI with a patient, anticipate the anxiety this generates. Explain clearly what you are looking for and why the clinical features are or are not reassuring.

Neurology Referral Criteria

●
Refer to neurology if:
- ●The diagnosis is uncertain or atypical features are present
- ●First-line and second-line medical treatments have failed or are not tolerated
- ●There are features suggesting secondary TN requiring structural investigation
- ●Surgical options are being considered
●Initial medical management with carbamazepine is appropriate at GP level for a classic presentation — neurology referral is not required as an immediate first step in a straightforward case.

Driving and Carbamazepine

●Carbamazepine can cause drowsiness, dizziness, and visual disturbance, particularly during the titration phase — this impairs the ability to drive safely.
●Advise the patient not to drive until they know how the medication affects them. Once stable on an established dose without relevant side effects, driving may resume.
●The condition itself (sudden, severe, incapacitating pain attacks) may also render driving unsafe — this is relevant even before starting treatment.
●Document that driving advice was given.

Safety Netting and Follow-Up

●
Advise the patient to seek urgent review if:
- ●New neurological symptoms develop: facial numbness, facial weakness, visual changes, hearing loss
- ●A widespread rash, mouth ulcers, or blistering develop after starting carbamazepine (possible SJS — stop the drug and seek same-day assessment)
- ●Pain becomes continuous rather than episodic
- ●Unable to maintain adequate oral intake (fluid and nutrition)
●Arrange a follow-up appointment within 1–2 weeks to: review pain response and tolerability of carbamazepine, check blood results, review blood pressure (given amlodipine interaction), and assess whether dose titration is needed.
●TN can have a relapsing and remitting natural history — periods of remission may allow dose reduction or cessation under guidance.

Mapped to the RCGP curriculum topic: Ear, Nose and Throat.

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