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PLAB 2 Headache Station: How to Approach, SAH Red Flags & Free Practice

Headache is one of the most clinically loaded presentations in PLAB 2. The eight minutes test whether you can separate a benign primary headache from a life-threatening secondary cause - particularly subarachnoid haemorrhage - and act on the red flags in time. You will be given a focused history task with a patient describing a severe, sudden-onset headache, and you must take the history, request examination findings and investigations from the station panel, communicate the suspected diagnosis and outline a safe immediate plan. This guide walks through the structure that scores well in the marking matrix, the red flags you must not miss, and the specific safety-critical actions that separate a clear pass from a borderline fail.

Last reviewed 2026-05-15 · Reading time about 8 minutes

What the station is testing

The station is marked across three domains - data gathering, clinical management and interpersonal skills - plus three safety-critical checks: that an urgent non-contrast CT head was ordered, that the thunderclap red-flag features were explicitly recognised, and that the patient was not discharged with simple analgesia. Miss any of these and the Clinical Management domain collapses to Clear Fail regardless of how well the rest went.

Hold these differentials in your head

Bracket the deadly causes first. If you fail to consider any of these in your reasoning out loud, the clinical-management domain will suffer.

  • Subarachnoid haemorrhage (SAH)
    Thunderclap onset reaching maximum intensity within a minute, often described as the worst headache of the patient's life. Photophobia, neck stiffness and vomiting commonly follow. This is the diagnosis PLAB 2 is testing.
  • Bacterial meningitis
    Headache with fever, neck stiffness, photophobia and sometimes a non-blanching petechial rash. Looks for systemic infection signs and a shorter sub-acute time course than SAH.
  • Encephalitis
    Headache with fever and altered consciousness or behaviour. Herpes simplex is the cause to actively rule out. Often confusion or seizure rather than pure photophobia.
  • Migraine
    Unilateral, throbbing, builds over minutes to hours rather than seconds. May have visual or sensory aura. Personal or family history is common. Not thunderclap.
  • Tension-type headache
    Bilateral, band-like, gradual onset, often stress or screen-related, no neurological features. Should never be your first answer in a sudden-severe headache station.
  • Giant cell arteritis (temporal arteritis)
    Patient over 50 with new headache, scalp tenderness, jaw claudication or visual disturbance. Sight-threatening without urgent high-dose steroids; check ESR/CRP.
  • Acute angle-closure glaucoma
    Severe headache with a red painful eye, visual halos around lights and nausea. Easy to miss if you do not specifically ask about eye pain or vision.
  • Cerebral venous sinus thrombosis
    Sub-acute or thunderclap headache in patients with thrombotic risk: oestrogen-containing contraception, pregnancy, post-partum, malignancy, thrombophilia.

Step-by-step approach

This is the structure that scores. You do not need to follow it verbatim, but every numbered block below maps to a cluster of marks in the rubric.

  1. 1. Open the consultation

    Set a calm, professional tone before any clinical questions.

    • Wash hands, greet, introduce yourself with name and grade.
    • Confirm the patient's full name and date of birth.
    • Explain you are the doctor seeing them today and you understand they have come in with a severe headache.
    • Acknowledge how frightening severe head pain feels - empathy now banks interpersonal marks.

  2. 2. SOCRATES with a thunderclap focus

    Every letter is a mark. The onset question is the highest-yield single item in the whole station.

    • Site - where on the head; ask them to point.
    • Onset - sudden over seconds, building over minutes, or gradual? This is the thunderclap question.
    • Character - hit on the back of the head, tight band, throbbing, tearing?
    • Radiation - to the neck or face?
    • Time course - constant, worsening, settling? When did it peak?
    • Severity - 1 to 10 now and at its worst. Worst-ever question explicitly.
    • Exacerbating / relieving factors - light, sound, movement, position, valsalva.

  3. 3. Screen the red flags

    A clean red-flag sweep is the difference between an Acceptable and an Excellent data-gathering band.

    • Thunderclap onset (seconds to a minute to maximum intensity).
    • Worst headache of their life.
    • Vomiting, photophobia, neck stiffness.
    • Loss of consciousness, even briefly, around onset.
    • Focal neurological symptoms - weakness, numbness, slurred speech, visual change.
    • Fever or rash - to consider meningitis.
    • Recent head injury or trauma.
    • Previous similar headaches or chronic headache pattern (or, importantly, the absence of one).

  4. 4. Complete the medical history

    Round out past medical, drug and allergy history before moving on.

    • Past medical history - hypertension, bleeding disorders, polycystic kidney disease, previous bleeds.
    • Medications - especially anticoagulants, antiplatelets, the combined oral contraceptive pill.
    • Allergies.
    • Family history - explicitly ask about brain bleeds, aneurysms or strokes in first-degree relatives.
    • Social history - smoking, alcohol, occupation.

  5. 5. Ideas, concerns and expectations

    A patient with the worst headache of their life is frightened. Surface it directly.

    • "Is there something in particular you are worried this might be?"
    • Common answers: a stroke, a bleed, dying, a tumour.
    • Acknowledge the fear, do not dismiss it. Honest reassurance only after the diagnosis is clearer.

  6. 6. Request examination findings

    Address the station for the findings - this is a marked block.

    • Vital signs - blood pressure, heart rate, respiratory rate, temperature, oxygen saturation.
    • Full neurological examination - GCS, cranial nerves, motor and sensory exam, reflexes, plantars, coordination, gait if able.
    • Neck stiffness and Kernig's sign.
    • Fundoscopy - papilloedema, subhyaloid haemorrhage.
    • General examination - look for rash, signs of systemic infection.

  7. 7. Request investigations

    Urgent CT is the safety-critical investigation. Naming it costs you nothing and missing it costs you the station.

    • Urgent non-contrast CT head. This is the cornerstone investigation for thunderclap headache.
    • Lumbar puncture only if CT is negative and over 12 hours have elapsed since onset (xanthochromia).
    • Routine bloods - FBC, U&Es, clotting, CRP, glucose, group and save.
    • Blood cultures if any infective features.
    • ECG - particularly if older or hypertensive.

  8. 8. Communicate the suspected diagnosis

    Be honest, plain, and follow it with what happens next. False reassurance loses marks.

    • "Given how sudden and how severe the pain has been, the main thing we need to rule out is a bleed in the brain - a subarachnoid haemorrhage."
    • Mention one or two alternatives so the patient knows you have considered them.
    • Pause - let the news land. Tolerate the silence.
    • Check understanding before moving to the management plan.

  9. 9. Outline immediate management

    Admit, refer, treat the pain and the pressure. Do not send home.

    • Admit for monitoring and the CT. Do not discharge.
    • Analgesia (paracetamol; opioids cautiously if needed) and an antiemetic.
    • Control blood pressure if significantly raised, per local protocol.
    • Discuss with neurosurgery if CT confirms or strongly suggests SAH.
    • Bed rest, head of bed elevation, calm environment, observations.
    • Nimodipine consideration in confirmed SAH per neurosurgical advice.

  10. 10. Safety-net and close

    Even an admitted patient needs explicit safety-netting language.

    • Tell the patient to alert staff immediately if the pain worsens, vomiting increases, vision changes or they feel weak.
    • Confirm they understand they are staying for observation and the CT.
    • Invite final questions, thank them, close.

Common pitfalls

  • Not asking about speed of onset specifically - "how long did it take to reach the worst?" is the single most important question and the most common omission.
  • Forgetting to ask whether this is the worst headache of their life.
  • Skipping family history of brain bleeds or aneurysms - it is a graded item and often a major clue.
  • Not requesting the CT head out loud, even when it would obviously be done.
  • Discharging the patient with paracetamol and a return-if-worse safety-net - this is a safety-critical fail.
  • Failing to mention LP would follow if the CT is negative and the suspicion remains.
  • Reassuring the patient prematurely ("don't worry, it's probably just a migraine") before the CT.
  • Skipping fundoscopy - it is a low-effort item that buys marks.

Frequently asked questions

What is a thunderclap headache?

A thunderclap headache is one that reaches maximum intensity within a minute of onset - often described by patients as being hit on the back of the head. It is the cardinal symptom of subarachnoid haemorrhage and the single most important detail to elicit in the PLAB 2 headache station.

Why is CT the first investigation in a thunderclap headache?

Non-contrast CT within six hours of onset is over 95% sensitive for subarachnoid haemorrhage and can be done immediately in any UK emergency department. NICE guidance and Royal College of Emergency Medicine pathways both place an urgent CT head first - it is the safety-critical action you must mention out loud.

When is a lumbar puncture indicated?

An LP is indicated if the CT head is negative and clinical suspicion of SAH remains. You should wait at least 12 hours from headache onset before performing the LP to allow xanthochromia (yellow discolouration of CSF from haemoglobin breakdown) to develop. You do not need to mention LP if you cannot also mention the 12-hour timing.

Should I ever discharge a patient with a thunderclap headache?

No. The PLAB 2 station marks early discharge of a thunderclap-headache patient as a safety-critical fail. Even if the patient feels better and the pain has settled, the station expects you to admit for CT and observation.

What if the patient is over 50 with new-onset headache and scalp tenderness?

Consider giant cell arteritis. Ask about jaw claudication, visual disturbance and proximal muscle aches. Check ESR and CRP urgently and start empirical high-dose oral prednisolone if suspicion is high - delay risks permanent visual loss. Refer to rheumatology for temporal artery biopsy within a week.

Can I practise the PLAB 2 headache station for free?

Yes. Plabity gives every new user one free station credit on signup. The thunderclap headache station is available immediately - you speak with a simulated patient in real time, request the findings you want, and receive a PLAB-rubric-aligned mark scheme with personalised feedback at the end.

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