History Taking · Intermediate · Neurology

Bilateral Band-like Headache

Practise this PLAB 2 history taking station on Tension-Type Headache. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mr David Foster, a 42-year-old man, has come to see you with a persistent bilateral headache that feels like a tight band around his head. The pain is chronic and worsening. He works in IT with a high-stress job and has been under significant pressure for the past six months. Please take a focused history to differentiate from migraine and secondary causes.

Background notes: PMH: Hypertension, Appendicitis/appendectomy (university), Measles (childhood)

What this station tests

  • Applying IHS criteria for tension-type headache: bilateral, band-like, pressing, mild to moderate, not worsened by activity, no nausea, no photophobia
  • Distinguishing TTH from migraine through the negative features: absence of nausea, vomiting, photophobia, phonophobia, and activity worsening
  • Systematic secondary headache red flag screening: new onset >50, thunderclap, focal neurology, early morning pattern, and weight loss
  • Identifying medication-overuse headache risk: daily paracetamol use over 15 days/month contributing to chronic headache
  • Addressing the underlying causes: stress, posture, sleep, and screen time rather than purely pharmacological management

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Chronic daily headache in an adult requires confident diagnosis of the primary headache type while excluding secondary causes through targeted red flag screening. The candidate must demonstrate that they can reassure without premature closure. Mr Foster is 42, presenting with six months of bilateral band-like headache, now present almost every day. He works in a high-stress IT role. Open with: 'Mr Foster, tell me about these headaches. What do they feel like and how are they affecting you?' Let him describe the impact alongside the symptoms.

Core approach

Establish the tension-type headache pattern through the IHS criteria. The headache is bilateral, band-like ('like a tight band all the way around my head'), pressing and tightening in quality, mild to moderate intensity. It does not prevent him from working but is constant and worsening. The critical negative features are equally important: no nausea, no vomiting, no photophobia, no phonophobia, and not worsened by physical activity. These negatives distinguish TTH from migraine (which has nausea/vomiting, photophobia, and is worsened by activity).

Screen for secondary headache red flags systematically. New onset after age 50? No, he is 42. Thunderclap onset? No, gradual over months. Focal neurological symptoms? None. Visual changes? None. Early morning headache with vomiting (raised ICP)? No. Worsening on coughing or straining (Chiari, mass)? No. Weight loss, fever, night sweats? No. Temporal tenderness, jaw claudication (GCA)? No, too young. These red flags must be explicitly asked and documented to justify a primary headache diagnosis.

Assess the chronic pattern. Present almost daily for six months, worse later in the day, never completely absent, slightly better at weekends. His neck and shoulders are constantly tense. He works long hours at a computer, commutes 30 minutes, has a major project going live, staff shortages, and sleeps poorly because of work worry. He is self-medicating with paracetamol 'most days,' which raises the concern of medication-overuse headache (MOH). Ask specifically about frequency of paracetamol use: if more than 15 days per month, MOH is a contributing factor.

ICE: He thinks it is stress-related and will resolve when the work project finishes. He is somewhat dismissive but underneath is worried about a brain tumour (though he downplays this). He wants a quick fix (tablets) rather than lifestyle change.

Closing and safety netting

Provide a confident diagnosis with explanation: 'Mr Foster, based on what you have described, this is a chronic tension-type headache. The band-like pressure, the link to stress and poor posture, and the absence of features like nausea or visual disturbance all point to this diagnosis. I am not concerned about anything more serious.' If he asks about a brain tumour (and he probably will), address it directly: 'Brain tumours typically cause headaches that are worse in the morning, worsen over weeks with other symptoms like vision changes or vomiting. Your pattern does not fit that at all.'

Address the medication overuse risk. If he is taking paracetamol most days: 'Taking painkillers more than 15 days a month can actually make headaches more frequent. This is called medication-overuse headache. Reducing the paracetamol may feel counterintuitive, but it can actually improve things.'

Management: address the underlying causes rather than just treating the symptom. Stress management strategies, sleep hygiene, regular exercise (which reduces TTH frequency), posture correction at his desk, regular breaks from screen work. Pharmacological: if prophylaxis is needed, low-dose amitriptyline at night can reduce headache frequency and improve sleep. Consider physiotherapy referral for neck tension. Safety net: 'If you develop a sudden severe headache unlike anything before, vision changes, weakness, or the headache wakes you from sleep with vomiting, come in urgently.'

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for tension-type headache. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: IHS criteria established: bilateral, band-like, pressing, no nausea, no photophobia, not worsened by activity. Systematic red flag screening documented. Medication-overuse assessment (frequency of paracetamol). Occupational and psychosocial factors identified: stress, posture, sleep, screen time.

Costs marks: Not establishing the negative features that exclude migraine. Not screening for red flags. Not checking paracetamol frequency. Not exploring occupational triggers.

Domain 2: Clinical Management Skills (Secondary focus)

Scores well: Confident primary headache diagnosis with clear rationale. Medication-overuse headache identified and addressed. Non-pharmacological management emphasised: stress management, posture, exercise, sleep hygiene. Amitriptyline as prophylaxis option. Physiotherapy referral. Clear red flag safety netting.

Costs marks: Requesting a CT scan for a primary headache (unnecessary investigation). Prescribing more painkillers without addressing MOH. No non-pharmacological management. No safety netting.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Providing confident reassurance without hedging. Addressing the brain tumour fear directly. Acknowledging the impact of work stress without trivialising it. Exploring whether he is ready to make lifestyle changes. Not dismissing his symptoms as 'just stress.'

Costs marks: Hedging the reassurance ('it's probably nothing serious'). Not addressing his hidden fear. Being dismissive of his symptoms. Insisting on lifestyle changes without exploring readiness.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not screening for red flags. A six-month worsening headache requires explicit secondary cause exclusion before diagnosing primary TTH. Candidates who say 'this is tension headache' without asking about thunderclap onset, focal neurology, and early morning pattern demonstrate premature diagnostic closure.
  2. Not identifying medication-overuse headache. Mr Foster takes paracetamol 'most days.' If this exceeds 15 days per month, it is contributing to the chronicity of his headaches. Candidates who prescribe more painkillers without checking for MOH risk worsening the problem.
  3. Not addressing the hidden brain tumour fear. He is somewhat dismissive ('just stress') but underneath is worried about something serious. If the candidate does not create space for this concern, he leaves with unaddressed anxiety. Candidates who address it directly ('I am not concerned about a tumour because...') provide genuine reassurance.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the tension-Type headache history in this PLAB 2 station?

Chronic daily headache in an adult requires confident diagnosis of the primary headache type while excluding secondary causes through targeted red flag screening. The candidate must demonstrate that they can reassure without premature closure. Mr Foster is 42, presenting with six months of bilateral band-like headache, now present almost every day.

What are examiners marking in this tension-Type headache station?

Marks are won for: IHS criteria established: bilateral, band-like, pressing, no nausea, no photophobia, not worsened by activity. Systematic red flag screening documented. Marks are lost for: Not establishing the negative features that exclude migraine. Not screening for red flags. Not checking paracetamol frequency. Not exploring occupational triggers.

What is the most common mistake candidates make in this tension-Type headache station?

Not screening for red flags. A six-month worsening headache requires explicit secondary cause exclusion before diagnosing primary TTH. Candidates who say 'this is tension headache' without asking about thunderclap onset, focal neurology, and early morning pattern demonstrate premature diagnostic closure.

How do I prepare for this station if I have not managed tension-Type headache in clinical practice?

This station rewards process over personal experience. The skill being assessed: Distinguishing TTH from migraine through the negative features: absence of nausea, vomiting, photophobia, phonophobia, and activity worsening. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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