Secondary headache and raised intracranial pressure — formative SAQs

SAQ 1 — Eight-year-old with a progressive morning headache (10 marks, 15 minutes)

An eight-year-old boy is brought to your clinic with a six-week history of daily headache. The headache is present when he wakes in the morning, eases through the morning, and is made worse by coughing and bending. His mother describes early-morning vomiting two to three times a week, and his teacher has noticed he is quieter and less engaged at school. His general and neurological examination, including fundoscopy, is normal. ^[11]

a) Identify the red flags in this history, and explain why a normal examination does not make this headache safe. State the single most important examination finding that would convert this from a watchful-waiting scenario to an imaging-today scenario. (4 marks) ^{[3] [12]}

b) State your investigation of choice, the timing, and the reason this modality is preferred over computed tomography for this child. Explain why a lumbar puncture is not your first investigation. (3 marks) ^{[1] [11]}

c) Outline your disposition and safety-netting. Discuss the role of the HeadSmart symptom cluster in your reasoning, and explain how you would communicate the urgency to the family without causing disproportionate alarm. (3 marks) ^{[11] [10]}