History Taking · Intermediate · Neurology

Recurrent Unilateral Headache with Visual Aura

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

Clinical scenario

You are an FY2 doctor in a GP surgery. Miss Emma Watson, a 28-year-old woman, has come to see you with a history of recurrent migraine attacks. She often gets a visual warning before the headache starts - bright lights and zig-zag patterns. The headaches are severe, usually unilateral, and she sometimes vomits. She takes various over-the-counter medications and wants better control. Please take a focused history and discuss acute and prophylactic treatment options.

Background notes: PMH: Migraine with aura (age 20-21, increasing frequency), Tonsillectomy (age 8)

What this station tests

  • Confirming migraine with aura using IHS criteria: unilateral, throbbing, moderate-severe, with nausea/photophobia/phonophobia, preceded by typical visual aura
  • Identifying the combined contraception contraindication: migraine with aura plus combined hormonal contraception significantly increases stroke risk
  • Distinguishing aura from more concerning visual symptoms: gradual onset, fully reversible, consistent pattern across attacks
  • Appropriate acute and prophylactic treatment recommendations: triptans for acute, propranolol/topiramate/amitriptyline for prophylaxis
  • Assessing functional impact: work absences, relationship strain, and medication overuse as indicators for prophylaxis

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

Recurrent headache stations require the candidate to confirm the primary headache diagnosis using IHS criteria, screen for secondary causes, and address the patient's specific management needs. The combination of visual aura and contraception has a critical safety implication that candidates must identify. Miss Watson is 28, presenting with increasing frequency of migraine attacks preceded by visual aura (zigzag patterns, flashing lights). Open with: 'Tell me about these headaches and how they are affecting you.' Let her describe the full pattern before directing your questions.

Core approach

Confirm the migraine with aura diagnosis through the IHS criteria. Her headaches are unilateral (right temple to occiput), throbbing, severe, lasting 24 to 48 hours, with nausea, vomiting, photophobia, and phonophobia, worsened by physical activity. The aura is visual: zigzag patterns (fortification scotomata) and flashing lights lasting 20 to 30 minutes, followed by the headache. This is classic migraine with aura. Frequency is 1 to 2 per month, increasing, with menstrual association.

Screen for red flags. Any change in aura pattern? Any new neurological symptoms? Any headache that is 'different from usual'? Thunderclap onset? Worsening over months? All should be absent in a primary headache.

The critical safety question: what contraception does she use? Migraine with aura is a contraindication to combined hormonal contraception (pill, patch, ring) because it significantly increases stroke risk. If she is on the combined pill, she needs to switch to a progestogen-only method. This must be asked. Candidates who take a complete migraine history but do not check contraception in a young woman with aura miss a patient safety issue.

Assess current management. She takes over-the-counter medications with limited success. Ask what specifically: paracetamol, ibuprofen, triptans? Has she tried triptans (the most effective acute treatment for migraine)? Check for medication-overuse headache if using painkillers frequently. Assess impact: she misses work, her boss is getting impatient, and she feels guilty about the impact on her relationship.

Closing and safety netting

Management should cover both acute treatment and prophylaxis. Acute: triptans (sumatriptan 50 to 100mg) taken early in the attack are first-line for moderate to severe migraine. Antiemetic (metoclopramide or domperidone) alongside. Avoid opioids. Explain that triptans work best when taken at the start of the headache, not during the aura.

Prophylaxis is indicated because she has 1 to 2 attacks per month affecting her function. First-line options: propranolol (avoid if asthmatic), topiramate (requires contraception discussion as it is teratogenic), or amitriptyline. She should keep a headache diary to track frequency, triggers, and menstrual association.

Address the contraception issue directly: 'Migraine with aura increases stroke risk, and the combined pill adds to that. We need to discuss switching to a safer option.' Refer to her GP or contraception clinic. Safety net: 'If your aura changes, lasts longer than an hour, or you develop new symptoms like weakness or speech difficulty, come in urgently.'

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for migraine with aura. 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 confirmed through systematic history. Aura characterised (visual, duration, fully reversible). Red flag screening. Contraception checked. Current medication assessment including overuse screening. Trigger identification (menstrual, stress, sleep).

Costs marks: Not characterising the aura. Not checking contraception. Not screening for red flags. Superficial medication history.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Triptan prescribed for acute treatment with correct timing advice. Antiemetic alongside. Prophylaxis recommended with appropriate first-line options. Contraception change recommended with safety rationale. Headache diary. Referral pathway if needed.

Costs marks: No triptan. Recommending triptan during aura. Not recommending prophylaxis despite frequent attacks. Not addressing contraception safety. No headache diary.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Addressing work and relationship impact. Reassuring about the aura (frightening but benign). Explaining contraception change sensitively. Empowering her with a management plan rather than leaving her feeling helpless.

Costs marks: Dismissing the impact on her work and relationship. Not reassuring about the aura. Delivering the contraception change without explanation. Being overly clinical.

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 asking about contraception. A 28-year-old woman with migraine with aura on a combined oral contraceptive pill has a significantly elevated stroke risk. This is a patient safety issue, not a peripheral question. Candidates who complete the headache history without checking contraception demonstrate a dangerous knowledge gap.
  2. Recommending triptans during the aura phase. Triptans should be taken at the onset of the headache, not during the aura. This is a commonly tested pharmacological point.
  3. Not considering prophylaxis. With 1 to 2 attacks per month causing work absences, prophylaxis is indicated. Candidates who only discuss acute treatment miss the opportunity to reduce attack frequency and demonstrate knowledge of prophylactic options.

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

What is the best way to take a migraine with aura history in PLAB 2?

Recurrent headache stations require the candidate to confirm the primary headache diagnosis using IHS criteria, screen for secondary causes, and address the patient's specific management needs. The combination of visual aura and contraception has a critical safety implication that candidates must identify. Miss Watson is 28, presenting with increasing frequency of migraine attacks preceded by visual aura (zigzag patterns, flashing lights).

Where are marks won and lost in this migraine with aura station?

Examiners reward: IHS criteria confirmed through systematic history. Aura characterised (visual, duration, fully reversible). Red flag screening. Contraception checked. Current medication assessment including overuse screening. Candidates are penalised for: Not characterising the aura. Not checking contraception. Not screening for red flags. Superficial medication history.

Where do candidates most often go wrong in this station?

Not asking about contraception. A 28-year-old woman with migraine with aura on a combined oral contraceptive pill has a significantly elevated stroke risk. This is a patient safety issue, not a peripheral question.

Can I do well in this station without real-world experience of migraine with aura?

Structure beats experience here. Focus on identifying the combined contraception contraindication: migraine with aura plus combined hormonal contraception significantly increases stroke risk. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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