St Emlyn’s Lesson Plans

Assessing a new or changed headache

Use a thunderclap case and suspected giant cell arteritis to practise focused history, escalation and honest test interpretation.

Medical Students · 45-minute session

For learners

Before: Allow about 12 minutes in total.

When we meet: We will compare early and later negative CT reports and assess a new headache with visual symptoms suggesting giant cell arteritis.

After: choose a point to follow up in practice

For facilitators

Send: the learner preparation link before teaching.

Bring: Timeline on a board and the two written CT results and scan times in case 1.

Run: 45-minute session plan · 30-minute option

Before the session

If you are attending this session, complete the core preparation below before you come. Allow about 12 minutes in total.

Core preparation

NICE NG228 diagnosing subarachnoid haemorrhage · About 6 minutes

Read the initial-assessment and referral recommendations 1.1.1–1.1.7, then 1.1.10–1.1.15 on CT and lumbar puncture. Focus on the onset-to-scan interval and the conditions attached to an early negative CT.

https://www.nice.org.uk/guidance/ng228/chapter/Recommendations

BSR giant cell arteritis guideline executive summary · About 4 minutes

Read general principles 1–4 in the executive summary: initial treatment, urgency, specialist referral and the first assessment. Focus on what a visual symptom changes; the long-term treatment sections are optional.

https://academic.oup.com/rheumatology/article/59/3/487/5714025

Think about (allow 2 minutes): How does the time from headache onset to CT affect the meaning of a negative scan in suspected SAH?

Picture the scene

Triage records ‘not like my usual migraine’. Before deciding that the patient needs either reassurance or a scan, you need to understand what is different.

By the end of the session

Clarify onset, time to peak and associated symptoms rather than relying on a diagnostic label.
Explain the role of CT timing in a suspected subarachnoid haemorrhage pathway.
Recognise possible giant cell arteritis and urgent visual symptoms.

After the session

In your next headache history, record time to maximum pain in the patient’s own words rather than simply writing ‘sudden’.

Facilitator guide

Send learners the preparation link several days before teaching. Allow about 12 minutes in total.

Before learners arrive

Confirm local SAH testing/reporting arrangements and the urgent GCA/ophthalmology referral route.
Use written reports rather than copying unlicensed scans.

Equipment: Timeline on a board and the two written CT results and scan times in case 1.

Setup: Pairs receive different scan times, then explain why their next steps differ.

If the preparation has not been completed

Replace “Establish the essentials” with five minutes. Draw onset, maximum pain, ED arrival and scan on the board, using the two scan times in case 1. Spend two minutes placing the six-hour interval, two comparing the next steps in NICE, and one asking for a visual or jaw symptom that would change the urgency of case 2.

Suggested session plan

0–5 min — Explore. Ask what ‘different from usual’ means.
5–10 min — Establish the essentials. Build the onset-to-test timeline.
10–32 min — Discuss & Apply. Use 14 minutes for the CT comparison and 8 for the visual-risk case.
32–40 min — Consolidate. Ask pairs to explain the two CT timelines, then give the essential visual-history information in a GCA referral.
40–45 min — Reflect & Transfer. Ask learners to practise recording time to maximum headache intensity in the patient’s own words.

Start the discussion

Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.

Cases and discussion

Use these cases, or invite an anonymised case from the group that addresses the same questions.

Abrupt severe headache

A 59-year-old reports an abrupt severe occipital headache reaching maximum intensity within minutes. They are alert and have no focal deficit.

Add this information as the discussion develops:

Non-contrast CT was obtained 4 hours after onset and is reported by a radiologist as showing no SAH.
Change only the timeline: CT was obtained 10 hours after onset.

Ask the group:

What history still matters when examination is normal?
What does the early negative CT change under NICE?
How does the later negative scan change further investigation?

Discussion notes

Points to draw out:

Record exact onset and time to peak, exertion, associated neurological or systemic symptoms and the history of prior headaches. A normal examination does not independently exclude SAH.
When CT within 6 hours is negative and reported/documented by a radiologist, NICE advises not routinely offering LP; consider alternatives and seek specialist advice as appropriate.
After a negative CT performed more than 6 hours after onset, consider LP. When indicated, allow at least 12 hours after onset for CSF bilirubin testing.
These are supervised pathway decisions. They do not mean every headache requires CT or that every negative scan explains the symptoms.

Common misconceptions:

Timing the interval from arrival.
Treating a normal neurological examination or improvement after analgesia as exclusion.
Calling any severe headache a ‘thunderclap’ without asking how quickly it peaked.

For a more experienced group: Ask how meningitis, venous thrombosis, glaucoma or pregnancy-related disease could require a different pathway.

New temporal pain and transient visual disturbance

A 55-year-old has a new persistent frontotemporal headache and pain while chewing. They report a brief episode of visual dimming.

Add this information as the discussion develops:

An inflammatory marker is not markedly elevated.
A colleague suggests waiting for a biopsy appointment before starting treatment.

Ask the group:

Which detail makes this urgent?
Can an unremarkable inflammatory marker settle the question?
What needs to happen before confirmatory testing?

Discussion notes

Points to draw out:

Suspected GCA with visual symptoms needs urgent specialist assessment, including ophthalmology; communicate the visual history explicitly.
Where GCA is strongly suspected, prompt glucocorticoid treatment should not wait for confirmatory tests, under the responsible clinician’s direction.
Confirmation may use temporal or axillary artery ultrasound and/or biopsy according to the local pathway.
The steroid regimen depends on visual involvement and the specialist pathway; confirm it with the responsible clinician.

Common misconceptions:

Using normal inflammatory markers as a sole rule-out.
Assuming intermittent symptoms cannot represent important disease.
Waiting for permanent visual loss before escalating.

For a more experienced group: Practise explaining why urgent treatment may be necessary while the diagnosis is being confirmed.

Important clinical points

A normal examination does not exclude SAH.
Apply the CT timing rule only with its reporting and clinical conditions.
Suspected sight-threatening GCA must not wait for routine outpatient confirmation.

Closing the session

Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.

State where the CT clock starts.
Explain the difference between the 4-hour and 10-hour negative scans.
Give the key sentence in a GCA referral when vision has changed.

Key teaching points:

Clarify symptom onset, time to peak and any change from previous headaches.
Interpret investigation results using the appropriate timing and pathway.
Possible GCA with visual symptoms needs urgent assessment.

Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.

Adapting the discussion

Uncertainty and local practice

No brief headache list excludes every secondary cause. Reassess when the pattern, context or examination does not fit.

If the discussion drifts

Which feature changes the urgency or the next investigation?

For a more experienced group

Compare the harm of missed disease with the harms of unnecessary CT/LP, explaining uncertainty without a promise of zero risk.

A 30-minute version

30 minutes: opening 3, timeline 5, SAH case 12, GCA case 5, consolidation 3, reflection 2.

Evidence and guidance

NICE NG228 — SAH diagnosis and CT/LP timing.https://www.nice.org.uk/guidance/ng228/chapter/Recommendations
BSR GCA 2020 executive summary — Recognition, urgent treatment and confirmation options.https://academic.oup.com/rheumatology/article/59/3/487/5714025