Headache OSCE - Tension Headache

Diagnosis: Tension Headache

Case Overview

  • Age/Sex: 22-year-old female
  • Occupation: University student (undergraduate, studying for end-of-year exams)
  • Setting: Primary care / student health clinic
  • Chief complaint: "Headache"

Patient Script

Who I Am

I'm a 22-year-old university student, currently revising for finals and feeling pretty stressed.

What Brings Me In

I've had a headache on and off for the last couple of weeks and it's getting a bit annoying — I wondered if it's anything serious or if you can give me something to help.

My Story

For about two weeks now I've had a headache most days. It usually feels like a tight band across my forehead and temples, sometimes at the back of my head, and it's there by the evening after a day of studying. It's usually pretty mild to moderate, about a 3–4 out of 10, and I can still carry on working. It comes on gradually during the day and is worse when I'm tired or after long periods on my laptop. I take paracetamol sometimes and it helps a bit. I also notice my neck and scalp feel a bit tense at times. I started revising more about three weeks ago so the timing seems to match that.

My Medical Background

  • Past medical history: No major illnesses, had chickenpox as a child
  • Medications: Combined oral contraceptive pill (ethinylestradiol/levonorgestrel) for contraception; occasional paracetamol for headaches
  • Allergies: None known
  • Social: Non-smoker, drinks alcohol socially (1–2 drinks once or twice a week), drinks coffee (2–3 cups/day, more when revising), sleeps 4–6 hours/night during revision
  • Family history: Mother has migraine headaches

What I Think & Worry About

  • I think the headaches are probably from stress and lack of sleep, but I'm worried it might be something more serious like a brain problem.
  • I'm worried it will stop me performing well in my exams.
  • I want to know if it will get better without strong drugs and whether I should stop taking the pill or doing my revision.

If You Ask Me About Other Symptoms...

  • Vision: "Sometimes my vision gets a bit blurry when I'm really tired, but it goes away quickly and I don't get flashing lights."
  • Nausea/vomiting: "No, I haven't been sick and I don't feel nauseous with the headaches."
  • Photophobia/phonophobia: "If the lights are bright or it's noisy, it makes the headache a bit worse, but it's not unbearable."
  • Fever/URI symptoms: "I had a mild runny nose and sore throat about a month ago, but nothing like that now." (red herring)
  • Sinus/facial pain: "No pressure behind my eyes or face pain most of the time, sometimes my nose is a bit blocked when I'm tired." (red herring)
  • Neck stiffness or weakness: "My neck feels stiff after studying long hours, but I can move it and there's no weakness in my arms or legs."
  • Frequency of analgesics: "I usually take paracetamol maybe 2–3 times a week when it bothers me, but not every day." (helps rule out medication-overuse)
  • Recent head injury: "No recent knocks to the head."

Clinical Summary

Examination

  • General: Alert, well-looking young woman; appears mildly fatigued
  • Vitals: BP 110/70 mmHg, HR 72 bpm, RR 14/min, Temp 36.8°C, SpO2 98% on room air
  • Head and neck: No scalp tenderness, pericranial muscle tenderness on palpation (bilateral temporalis and trapezius)
  • Eyes: Visual acuity 6/6 each eye, pupils equal and reactive, fundoscopy normal (no papilloedema)
  • Cranial nerves: Intact (no focal deficits)
  • Neck: Supple, no meningism
  • Neurological: Normal power, tone, reflexes, coordination and gait

Investigations

  • Urine pregnancy test: Negative (rule out pregnancy-related causes)
  • Full blood count: Hb 140 g/L, WCC 7.2 x10^9/L, platelets 250 x10^9/L (no evidence of infection or anaemia)
  • CRP: 1 mg/L (normal; no inflammatory process)
  • Thyroid function (TSH): 1.8 mIU/L (within reference range)
  • No imaging performed (CT/MRI not indicated in absence of red flags)

Diagnosis

  • Primary diagnosis: Tension-type headache (episodic)

    • Evidence: Bilateral, pressing/tightening quality; mild–moderate intensity; not aggravated by routine physical activity; daily/evening timing related to prolonged study and poor sleep; pericranial muscle tenderness; absence of nausea/vomiting, aura, focal neurological signs, fever, or papilloedema.

  • Differentials:

    • Migraine: Less likely — headache is not unilateral or throbbing, no significant nausea/vomiting, no disabling photophobia/phonophobia or aura, and symptoms are more consistent with muscle-tension pattern.
    • Sinusitis: Unlikely — no purulent nasal discharge, facial pain/pressure or fever; normal CRP and WCC.
    • Medication-overuse headache: Unlikely currently — analgesic use is intermittent (paracetamol 2–3 times/week), below typical thresholds for overuse.
    • Cervicogenic headache: Considered — neck muscle tenderness and posture-related aspects could contribute; focal neck pathology not suggested on exam.

Management

  • Reassurance that features are consistent with episodic tension-type headache and not suggestive of serious intracranial disease.
  • Advise non-pharmacological measures:
    • Improve sleep hygiene (aim for 7–8 hours/night), regular sleep–wake schedule
    • Take regular breaks from screens, optimize ergonomics at study desk, adjust screen height and chair
    • Stress-management techniques: short relaxation exercises, progressive muscle relaxation, short walks, and pacing revision
    • Physiotherapy or simple stretching exercises for neck and shoulder muscles
  • Pharmacological measures:
    • Simple analgesia as needed: paracetamol 500–1000 mg or ibuprofen 200–400 mg (if no contraindications) for symptom relief
    • Advice to avoid regular daily analgesic use; limit to no more than 2–3 days per week to reduce risk of medication-overuse headache
  • Safety-net and follow-up:
    • Return or seek urgent care if worsening headache, new focal neurological signs, persistent vomiting, fever, or any visual loss
    • Review in 4–6 weeks if headaches persist or increase in frequency/severity; consider primary care review for physiotherapy referral, CBT, or prophylactic medication if frequent

Key Learning Points

  • Tension-type headache typically presents as bilateral, pressing/tightening pain of mild–moderate intensity, often associated with pericranial muscle tenderness and precipitated by stress, poor sleep or prolonged posture.

  • Always assess for red flags (acute severe ‘‘thunderclap’’ onset, focal neurological signs, persistent vomiting, fever, papilloedema, altered consciousness) that would prompt urgent imaging and referral.

  • Management emphasizes non-pharmacological measures (sleep hygiene, ergonomics, relaxation, physiotherapy) and cautious use of simple analgesics to avoid medication-overuse headache.

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