History Taking · Foundation · Neurology

Temporal Headache with Jaw Pain and Vision Changes

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

Clinical scenario

You are an FY2 doctor in a GP surgery. Mrs Margaret Black, a 74-year-old woman, has come to see you with a three-week history of temporal headache and jaw claudication. She mentions her vision blurred momentarily yesterday. She appears unwell and has lost weight recently. Please take a focused history and discuss your initial management.

Background notes: PMH: Type 2 Diabetes, Hypertension, Osteoarthritis knees, Cholecystectomy, Cataract surgery both eyes

What this station tests

  • Recognising the GCA triad: temporal headache with scalp tenderness, jaw claudication, and visual symptoms in a patient over 50
  • Identifying jaw claudication as the highest specificity symptom: cramping jaw pain on chewing that resolves with rest, initially mistaken for dental pathology
  • Treating before confirming the diagnosis when visual symptoms are present: same-day steroids to prevent irreversible blindness
  • Recognising PMR overlap: proximal morning stiffness in shoulders and hips, coexisting in 40 to 60% of GCA patients
  • Managing steroid initiation in a diabetic patient: explaining the glucose impact and the need for closer monitoring

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

Temporal headache in a patient over 50 is giant cell arteritis until proven otherwise. The candidate must recognise the pattern (temporal headache, jaw claudication, scalp tenderness, visual symptoms, constitutional features) and act urgently because of the risk of irreversible blindness. Mrs Black is 74, presenting with three weeks of temporal headache, jaw claudication for two weeks, and a brief episode of visual blurring yesterday. Open with: 'Mrs Black, tell me about this headache and the other symptoms you've been having.' The visual symptom should escalate your urgency.

Core approach

The headache is bilateral temporal, worse on the left, throbbing, present most days for three weeks. The temples are tender to touch (she cannot tolerate combs or pillows pressing on them). Jaw claudication is the critical finding: for two weeks, chewing or eating hard foods causes severe cramping pain in the jaw muscles that resolves when she stops chewing. She initially thought it was dental, but her dentist found nothing. Jaw claudication has the highest positive likelihood ratio of any symptom for GCA.

The visual episode is the red flag that makes this urgent. Yesterday afternoon, her vision in one eye went blurry for a few seconds, then returned to normal. This is amaurosis fugax and represents transient ischaemia of the optic nerve. Without treatment, 15 to 20% of GCA patients develop permanent vision loss from anterior ischaemic optic neuropathy. This symptom should accelerate your management from 'investigate soon' to 'treat today.'

Assess for polymyalgia rheumatica features. Her shoulders and hips have been stiff and achy, especially first thing in the morning, taking about an hour to loosen up. PMR coexists in 40 to 60% of GCA patients. Constitutional symptoms: weight loss (clothes are loose), fatigue, reduced appetite, feeling generally unwell for six weeks.

PMH: type 2 diabetes (relevant because steroids will worsen glucose control), hypertension, cataracts (she may worry about her eyes). ICE: she thinks the headache might be stress-related. The jaw pain confused her. The visual episode frightened her. She does not know what GCA is.

Closing and safety netting

This case requires same-day treatment. Do not wait for investigations to start steroids when there are visual symptoms. 'Mrs Black, the combination of your temporal headache, the jaw pain when chewing, the visual episode, your shoulder stiffness, and the weight loss all fit a condition called giant cell arteritis. This is inflammation of the blood vessels in your head. The reason I want to start treatment today is that the visual blurring you experienced yesterday tells me the blood supply to your eye was briefly affected. Without treatment, there is a risk of permanent vision loss.'

Start high-dose prednisolone immediately (typically 40 to 60mg daily; with visual symptoms, some guidelines recommend IV methylprednisolone first). Arrange urgent blood tests: ESR and CRP (expected to be significantly elevated), FBC, LFTs, glucose (baseline before steroids). Refer for temporal artery biopsy (ideally within 2 weeks of starting steroids, but do not delay treatment for biopsy). Ophthalmology review urgently given visual symptoms.

Address the diabetes concern: steroids will raise her blood glucose and she will need closer monitoring and likely insulin adjustment. Explain that the steroid dose will be gradually reduced over months. Safety net: 'If your vision changes again in any way, go to A&E immediately and tell them you are being treated for giant cell arteritis.' Bone protection (calcium, vitamin D) should be started alongside steroids.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for giant cell arteritis. 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: Complete GCA symptom assessment: temporal headache with scalp tenderness, jaw claudication, visual symptoms (amaurosis fugax), PMR features, constitutional symptoms. Checking temporal artery tenderness. Assessing visual acuity. PMH relevant to steroid use (diabetes).

Costs marks: Not asking about jaw claudication. Not enquiring about visual symptoms. Missing PMR features. Not checking diabetes status before starting steroids.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Same-day high-dose prednisolone initiated despite pending investigations. Urgent bloods (ESR, CRP). Temporal artery biopsy referral within 2 weeks. Urgent ophthalmology review. Bone protection. Diabetic glucose monitoring plan. Vision-specific safety netting.

Costs marks: Delaying steroids for investigation results. Not arranging biopsy. Not referring to ophthalmology. Not addressing steroid impact on diabetes. No vision-related safety netting.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Explaining GCA and the urgency of treatment in plain language. Addressing her fear about the visual episode honestly. Explaining why steroids are needed today. Managing the diabetes concern with a practical plan rather than creating anxiety.

Costs marks: Being vague about why treatment is urgent. Not addressing the visual symptom's significance. Causing unnecessary alarm about steroid side effects. Not explaining the biopsy.

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. Waiting for blood results or biopsy before starting steroids. With visual symptoms (amaurosis fugax), GCA is a medical emergency. Delaying treatment for a day to get ESR results risks permanent blindness. Candidates must start steroids today.
  2. Missing jaw claudication. Mrs Black's jaw pain is the most specific symptom for GCA, but she initially thought it was dental and her dentist found nothing. Candidates who do not ask about pain on chewing, or who accept the dental attribution, miss the most discriminating feature.
  3. Not arranging ophthalmology review. The visual episode indicates threatened vision. Candidates who start steroids but do not arrange urgent ophthalmology assessment leave the vision unmonitored.

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 do I approach the consultation in this giant cell arteritis station?

Temporal headache in a patient over 50 is giant cell arteritis until proven otherwise. The candidate must recognise the pattern (temporal headache, jaw claudication, scalp tenderness, visual symptoms, constitutional features) and act urgently because of the risk of irreversible blindness. Mrs Black is 74, presenting with three weeks of temporal headache, jaw claudication for two weeks, and a brief episode of visual blurring yesterday.

What does a strong performance look like to the examiner in this station?

Strong performances show: Complete GCA symptom assessment: temporal headache with scalp tenderness, jaw claudication, visual symptoms (amaurosis fugax), PMR features, constitutional symptoms. Weak performances: Not asking about jaw claudication. Not enquiring about visual symptoms. Missing PMR features. Not checking diabetes status before starting steroids.

What is the biggest pitfall in this giant cell arteritis station?

Waiting for blood results or biopsy before starting steroids. With visual symptoms (amaurosis fugax), GCA is a medical emergency. Delaying treatment for a day to get ESR results risks permanent blindness.

How should I prepare for giant cell arteritis if I have never seen it in practice?

Structure beats experience here. Focus on identifying jaw claudication as the highest specificity symptom: cramping jaw pain on chewing that resolves with rest, initially mistaken for dental pathology. 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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