Headache OSCE - Migraine with Aura

Case Overview

• Age/Sex: 33-year-old female
• Occupation: Office worker (administrative assistant)
• Setting: Primary care / urgent clinic
• Chief complaint: "Headache"

Patient Script

Who I Am

I am a 33-year-old woman who works in an office and has been under a lot of stress at work lately.

What Brings Me In

I keep getting these really bad headaches that start after I see flashing lights and make me feel sick — it happened again this morning and I wanted it checked out.

My Story

About 6 months ago I started having headaches every few weeks. Usually, about 20–30 minutes before the headache I notice bright, zig-zaggy lines and a patch of my right side of vision gets a bit dim — it lasts for around half an hour, then a bad headache comes on. The headache is usually on the left side, throbbing, gets worse with movement and bright lights, and comes with nausea and some sensitivity to sound. The pain lasts 6–24 hours if I don’t take anything. This morning it started the same way: I saw flashing lights for about 20 minutes, then the headache began and I felt queasy, so I came in.

I sometimes take paracetamol or ibuprofen which helps a little. I’ve also had a bit of a sore throat and a runny nose last week (thought it was a sinus infection), and my neck has been a bit stiff from sitting at my desk — but that’s normal for me. I’m not pregnant and I’m on the combined oral contraceptive pill. I don’t smoke; I drink 1–2 coffees a day and a glass of wine occasionally.

My Medical Background

• Past medical history: mild eczema; no previous major illnesses
• Medications: combined oral contraceptive pill (ethinylestradiol/levonorgestrel), occasional paracetamol or ibuprofen
• Allergies: none known
• Social: lives with partner, no smoking, drinks 3–6 units alcohol/week, works long hours, sleeps poorly when stressed
• Family history: mother gets migraines

What I Think & Worry About

• I think these are migraines because my mother had them and the lights come before the headache.
• I’m worried this might be something serious like a stroke because of the visual changes, or that the pill might make things worse.
• I want to know if there’s something I should stop (like the pill), and how to stop the headaches so they don’t ruin my work.

If You Ask Me About Other Symptoms...

• Vision now: the flashing lights are gone and my vision has returned to normal.
• Weakness/speech: I have not had any weakness or trouble speaking.
• Fainting/dizziness: I felt a bit lightheaded once during a headache but didn’t faint.
• Fever/cold symptoms: I had a mild runny nose and sore throat last week but no fever now.
• Neck stiffness: I have some soreness in the neck from posture, but no severe stiffness or photophobia outside the headache.
• Medication overuse: I use simple painkillers occasionally (maybe 5–8 days/month), not every day.

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Clinical Summary

Examination

• General: alert, comfortable between headaches
• Vital signs: BP 118/76 mmHg, HR 82 bpm, RR 14/min, Temp 36.7°C, SpO2 98% on air
• HEENT: no nasal polyps or purulent discharge; tympanic membranes normal; no focal sinus tenderness
• Eyes: pupils equal and reactive, extraocular movements full, no ptosis, visual fields to confrontation full (between attacks), no papilloedema on fundoscopy
• Neck: mild paraspinal muscle tenderness; no meningism
• Neurological: cranial nerves II–XII intact; power 5/5 in all limbs; sensation intact; reflexes normal; gait normal

Investigations

• Pregnancy test (urine): negative (rules out pregnancy-related causes and informs contraception discussion)
• Full blood count: WBC 7.4 x10^9/L, Hb 13.2 g/dL, platelets 260 x10^9/L (no infection or cytopenia)
• CRP: 1 mg/L (not inflammatory)
• CT head (non-contrast): normal (no acute intracranial hemorrhage or mass — performed if acute severe/first attack or atypical features were present)
• ECG: sinus rhythm 80 bpm (no arrhythmia)

Diagnosis

Primary diagnosis: Migraine with aura

• Evidence: recurrent attacks over 6 months with stereotyped visual aura of bright, zig-zag lines and transient visual disturbance lasting ~20–30 minutes followed by a unilateral throbbing headache associated with photophobia, phonophobia and nausea; normal interictal neurological examination and normal CT head.

Differential diagnoses and reasoning:

• Transient ischaemic attack (TIA): considered because of transient visual disturbance, but TIA typically has sudden onset symptoms, risk factors, and no preceding positive visual phenomena like scintillating scotoma; CT normal and symptoms stereotyped and recurrent consistent with migraine aura.
• Occipital lobe seizure: can cause visual phenomena, but seizures are usually brief (seconds), may have positive motor phenomena or impaired awareness — history of gradual spread and longer-lasting (20–30 min) positive visual symptoms favors migraine aura.
• Tension-type headache: typically bilateral, pressing quality, not associated with aura, photophobia or nausea — less likely.
• Sinusitis-related headache: history of recent rhinitis is a red herring; exam lacks focal sinus tenderness/purulent discharge and symptoms follow aura pattern, so sinusitis unlikely as primary cause.

Management

• Acute treatment:
  • Offer NSAID (e.g., naproxen 500 mg PO then 250–500 mg PRN) or high-dose paracetamol as first-line for mild-moderate attacks.
  • If attacks are moderate–severe and no vascular contraindications, consider a triptan (e.g., sumatriptan 50–100 mg PO at onset) with antiemetic (metoclopramide 10 mg PO/IM) if nausea severe.
  • Advise early treatment at onset of headache; treat aura-associated pain early if pain follows aura.
• Preventive and risk discussions:
  • Discuss that migraine with aura increases stroke risk, and combined oral contraceptives are generally not recommended in women with migraine with aura; discuss alternative contraception (progestin-only methods or non-hormonal options) and arrange follow-up with GP or contraceptive clinic.
  • If headaches are frequent (e.g., ≥4 attacks/month) or disabling, discuss preventive therapy options (e.g., propranolol, amitriptyline, topiramate) and lifestyle measures (regular sleep, hydration, limit caffeine, manage stress, trigger diary).
• Safety net / red flags and urgent actions:
  • Advise immediate ED review if she develops a sudden, severe "worst headache", new persistent focal neurological deficit, prolonged aura (>60 minutes), loss of consciousness, or fever with neck stiffness.
• Follow-up:
  • Arrange primary care/neurology follow-up in 4–6 weeks; document consideration of MRI brain only if atypical features emerge or aura patterns change.

Key Learning Points

• Migraine with aura is characterised by reversible focal neurological symptoms (commonly visual scintillations or scotoma) that typically precede the headache by minutes and last <60 minutes; the headache is often unilateral, throbbing, and associated with photophobia, phonophobia and nausea.

• Distinguish migraine aura from TIA or occipital seizures by onset, duration, repetitiveness and positive visual phenomena (scintillating scotoma and gradual spread favour migraine); persistent or atypical focal deficits, first-ever aura in older patients, or prolonged symptoms should prompt urgent investigation.

• Women with migraine with aura should be counselled about increased ischaemic stroke risk associated with combined hormonal contraceptives; consider alternative contraception and coordinate this discussion with primary care.