History Taking · Foundation · Neurology

Sudden Severe Headache with Neck Stiffness

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

Clinical scenario

You are an FY2 doctor in the Emergency Department. Ms Sarah Chen, a 52-year-old woman, has presented with a sudden-onset severe headache while shopping this morning. She describes it as the worst headache of her life. She is alert but in obvious pain, with neck stiffness. Please take a focused history and discuss your immediate management.

Background notes: PMH: Migraine without aura (occasional, age 18+), Hypertension

What this station tests

  • Recognising the thunderclap headache pattern: sudden onset, maximal immediately, worst headache of life, with meningism
  • Distinguishing SAH from migraine: onset pattern (instantaneous versus crescendo), character (explosive versus throbbing), and the patient's own comparison ('nothing like my normal migraines')
  • Asking about sentinel headache: 10 to 15% of SAH patients report a warning headache from a minor leak in preceding days
  • Urgent investigation pathway: CT head within 6 hours (>95% sensitivity), LP at 12 hours if CT negative, avoiding NSAIDs until SAH excluded
  • Communicating urgency while maintaining calm: acting fast without causing panic

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

Thunderclap headache is a neurosurgical emergency until proven otherwise. The candidate must recognise the pattern (sudden onset, maximal at onset, worst headache of life), act urgently, and distinguish SAH from other causes of severe headache. Ms Chen is 52, presenting with sudden-onset 'worst headache of her life' while shopping, with neck stiffness. She is alert but in severe pain. Keep the history focused and urgent: 'Ms Chen, I can see you are in a lot of pain. I need to ask you some important questions. Can you tell me exactly what happened?' The pace should match the emergency.

Core approach

The headache has the classic SAH signature: absolutely sudden onset ('like a thunderbolt,' 'like an explosion in my head'), maximal intensity immediately (not building over minutes or hours), global but worst at the back of the head and neck, with neck stiffness developing rapidly. She had photophobia immediately, nausea, and vomited once in the supermarket. The pain radiates down her neck and between her shoulder blades. Paracetamol had no effect. She has not lost consciousness and has no focal neurological deficit.

The key differentiator from migraine is the onset pattern. Ms Chen has a history of migraine without aura, and she will tell you this is completely different: 'This is nothing like my normal migraines.' Migraine develops over minutes to hours with a crescendo pattern. SAH is maximal at onset. This distinction must be actively established.

Screen for complications. Ask about limb weakness, speech difficulty, visual changes (none, which is reassuring but does not exclude SAH). Ask about preceding 'sentinel' headache: 10 to 15% of SAH patients report a warning headache in the preceding days or weeks from a minor leak. She may mention a headache a few days ago that was worse than usual. Ask about anticoagulant or antiplatelet use (none). PMH: migraine and hypertension (a risk factor for aneurysmal SAH).

ICE: She is terrified. She knows this is serious. She thinks it might be a stroke. She needs urgent investigation, not extended ICE exploration.

Closing and safety netting

Communicate with urgency and clarity. 'Ms Chen, the pattern of your headache, sudden and extremely severe with neck stiffness, is one we take very seriously. I need to arrange an urgent CT scan of your head right now to look for a possible bleed around your brain.' Do not sugarcoat but do provide reassurance through action: the team is acting quickly because quick action leads to better outcomes.

Immediate management: urgent non-contrast CT head (sensitivity >95% within 6 hours of onset). If CT is negative but clinical suspicion remains, lumbar puncture at 12 hours for xanthochromia. Analgesia (IV paracetamol, avoid NSAIDs until SAH excluded, cautious opioids if needed). Keep her nil by mouth in case of neurosurgical intervention. IV access. Continuous monitoring. Avoid straining or Valsalva. If CT confirms SAH: urgent neurosurgical referral for aneurysm coiling or clipping.

Acknowledge her fear: 'I know this is very frightening. We are getting you the scan as quickly as possible.' Ask if her husband or family should be contacted. Safety netting is built into the emergency pathway: she is not going home.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for subarachnoid haemorrhage. 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: Establishing thunderclap onset pattern. Distinguishing from migraine through direct comparison. Identifying meningism (neck stiffness, photophobia). Screening for focal neurology. Asking about sentinel headache. Identifying hypertension as a risk factor.

Costs marks: Not establishing the onset pattern. Accepting the migraine diagnosis. Not checking for meningism. Leisurely, unfocused history.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Urgent CT head arranged immediately. Knowledge of CT sensitivity (>95% within 6 hours). LP pathway if CT negative. Appropriate analgesia (paracetamol, not NSAIDs). Nil by mouth. Neurosurgical referral pathway for confirmed SAH.

Costs marks: Not arranging urgent CT. Prescribing NSAIDs. Not knowing the LP pathway. Sending patient home with analgesia.

Domain 3: Interpersonal Skills (Adapted to emergency)

Scores well: Calm, clear communication of urgency. Acknowledging her pain and fear. Reassurance through action ('we are getting you the scan now'). Contacting family. Brief but genuine empathy within the emergency context.

Costs marks: Causing panic through alarmist language. Ignoring her pain. Not contacting family. Being so clinical that she feels like a diagnosis rather than a person.

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. Attributing the headache to migraine because of her migraine history. She has migraines, but she is telling you this is completely different. Candidates who accept 'probably just a bad migraine' without establishing the onset pattern miss a potentially fatal diagnosis. Always ask: 'How quickly did the headache reach its worst?'
  2. Taking a leisurely history. This is a medical emergency. Spending 5 minutes on systematic PMH, social history, and comprehensive ICE is inappropriate. The history should be rapid and focused: characterise the headache, screen for complications, identify risk factors, and arrange the CT scan.
  3. Giving NSAIDs for pain relief before SAH is excluded. NSAIDs increase bleeding risk. Paracetamol IV is appropriate. Candidates who prescribe ibuprofen for a thunderclap headache demonstrate a management error.

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 subarachnoid haemorrhage history in PLAB 2?

Thunderclap headache is a neurosurgical emergency until proven otherwise. The candidate must recognise the pattern (sudden onset, maximal at onset, worst headache of life), act urgently, and distinguish SAH from other causes of severe headache. Ms Chen is 52, presenting with sudden-onset 'worst headache of her life' while shopping, with neck stiffness.

Where are marks won and lost in this subarachnoid haemorrhage station?

Examiners reward: Establishing thunderclap onset pattern. Distinguishing from migraine through direct comparison. Identifying meningism (neck stiffness, photophobia). Screening for focal neurology. Candidates are penalised for: Not establishing the onset pattern. Accepting the migraine diagnosis. Not checking for meningism. Leisurely, unfocused history.

Where do candidates most often go wrong in this station?

Attributing the headache to migraine because of her migraine history. She has migraines, but she is telling you this is completely different. Candidates who accept 'probably just a bad migraine' without establishing the onset pattern miss a potentially fatal diagnosis.

Can I do well in this station without real-world experience of subarachnoid haemorrhage?

This station rewards process over personal experience. The skill being assessed: Distinguishing SAH from migraine: onset pattern (instantaneous versus crescendo), character (explosive versus throbbing), and the patient's own comparison ('nothing like my normal migraines'). Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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