Simulated Patient Scenario

Migraine

Scenario Details

Scenario: Acute Migraine with Aura

Simulated Patient: 35-year-old Female

Actor/Actress: Student Actor (Patient)

MDT Information

Non-Urgent Response - Headache
35-year-old female with severe headache
History of migraines
Patient is conscious and alert, requesting assistance
Location: Office workplace

On Arrival

You arrive at an office building and are directed to a small, dimly lit first aid room. The patient, a 35-year-old female, is lying down on a couch with her eyes closed. She appears pale and distressed. She opens her eyes briefly as you enter but quickly closes them again, shielding them from the light. A vomit bowl is on the floor next to her.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Alert but appears unwell, in significant pain, photophobic.
Response	Alert and oriented, responds verbally but quietly. Prefers minimal light/noise. (AVPU = A)
Airway	Clear and self-maintaining.
Breathing	Rate and depth appear normal. No respiratory distress.
Circulation	Skin pale, possibly slightly clammy. Radial pulse palpable, slightly fast but regular.
Disability	Severe headache, photophobia, phonophobia. Possible residual visual disturbance.
Exposure/Environment	Indoor office environment (first aid room). Patient wearing work attire.

Secondary Survey and Simulation Progression

History (obtained from patient)

Allergies	NKDA
Medications	Sumatriptan (taken 1 dose ~1 hour ago with minimal relief), Ibuprofen (taken 2 tablets ~2 hours ago). Oral contraceptive pill.
Past Medical History	Migraine with aura (diagnosed ~10 years ago). Typically experiences 1-2 migraines per month, usually responds to Sumatriptan and rest. No history of seizures, stroke, recent head injury, or hypertension.
Last Oral Intake	Small lunch ~3 hours ago. Has vomited once since headache onset.
Events Preceding	Experienced typical visual aura (flashing lights, zig-zag lines) starting ~90 minutes ago, lasting about 20 minutes. This was followed by the onset of a severe, unilateral (left-sided), throbbing headache. Headache intensity increased over the next hour. Associated with significant nausea, photophobia (light sensitivity), and phonophobia (sound sensitivity). Vomited once about 30 minutes ago. Describes this headache as similar in character to previous migraines but more severe and not responding well to usual medication. Denies fever, neck stiffness, rash, focal weakness, or numbness (other than aura).

Vital Signs/Assessment (Initial)

Parameter	Value
Resp. Rate (/min.)	16
Lung Sounds (L/R)	Clear bilaterally.
SpO2 (%)	99% (Room Air)
EtCO2 (mmHg)	Not indicated
Pulse Rate (/min.)	95, regular
CRT (sec.)	< 2 sec
ECG rhythm	Sinus Tachycardia (likely pain/stress related)
12-lead ECG	Sinus rhythm/tachycardia. No acute changes. (Consider if atypical features or significant risk factors).
BP (mmHg)	140/85 (May be elevated due to pain)
Skin	Pale, slightly clammy.
Pain (/10)	9/10 severe, throbbing left-sided headache.
GCS (/15: E,V,M)	15/15 (E4, V5, M6)
BGL (mmol/L)	5.1
Pupils (mmL/mmR)	3mm L / 3mm R, Equal and Reactive (PERL)
Temp. (°C)	36.7

Physical Examination

General Appearance: Appears unwell, pale, photophobic, lying still in a dark room.
Head/Neck: No signs of trauma. Scalp non-tender. **No neck stiffness or Kernig's/Brudzinski's sign.** Temporal arteries non-tender.
Neurological: GCS 15. Cranial nerves intact (assess briefly - check eye movements, facial symmetry, gag reflex if concerned). Normal strength and sensation in all limbs. No ataxia or dysmetria. Normal reflexes. Patient reports sensitivity to light and sound.
Cardiovascular/Respiratory: Tachycardia noted. BP may be mildly elevated. Chest clear.
Other: Abdomen soft, non-tender. No rash.

Assessment and Treatment

Appropriate Management Focus

Primary Survey & Recognition: Recognize likely migraine based on history (previous similar episodes, aura, characteristic headache, associated symptoms).
Rule Out Red Flags: Systematically assess for features suggesting a more serious cause (e.g., "thunderclap" onset, fever, neck stiffness, new neurological deficit, worst headache ever, altered consciousness, seizure, trauma). Perform focused neurological exam.
Supportive Care & Environment: Maintain quiet, dark environment. Minimize unnecessary stimuli. Offer reassurance.
Pain Management:
- Consider IV access.
- Administer appropriate analgesia. Options may include:
  - IV Paracetamol.
  - NSAIDs (e.g., Ketorolac IV/IM if available and not contraindicated).
  - Consider IV/IM Opioids (e.g., Fentanyl, Morphine) for severe, refractory pain, used judiciously.
Antiemetic Therapy: Administer an antiemetic for nausea/vomiting (e.g., Ondansetron IV/IM/ODT, Prochlorperazine IV/IM - check local protocols). Often helps with headache relief too.
Fluid Therapy: Consider IV fluids (e.g., Sodium Chloride 0.9%) if patient is dehydrated from vomiting or unable to tolerate oral fluids.
Monitoring: Monitor vital signs, pain score, neurological status, and response to treatment.
Transport Decision: Transport to ED is appropriate given the severity, vomiting, and poor response to usual home treatment. Explain the need for further assessment and potentially different medications.
Teamwork & Communication: Clear communication with partner and patient. Provide clear handover to ED staff, including history of migraines, current symptoms, treatments given, and response.

Debrief Focus Points

Recognizing typical migraine features (unilateral, throbbing, aura, associated symptoms).
Importance of screening for headache red flags to exclude serious pathology.
Performing a focused neurological assessment.
Creating a supportive environment for migraine patients (low light/noise).
Pharmacological management options for acute migraine (analgesia, antiemetics).
Rationale for IV fluids in migraine management.
Decision-making regarding transport for severe/refractory migraine.