LONG CASE RESOURCE

Approach to Progressive Headache

Acromegaly • Pituitary Adenoma • MRCP (UK) PACES

A structured PACES approach to a patient presenting with progressive headache due to a growth hormone secreting pituitary adenoma. Learn focused history taking, examination, differential diagnosis, investigations, management and patient counselling.

10 min read Presenting Complaint Very High Yield

At a Glance

Presentation Progressive headache with changing facial appearance
Likely Diagnosis Acromegaly
Cause Growth Hormone secreting Pituitary Adenoma
Must Not Miss Pituitary Apoplexy
Key Investigation IGF-1, Oral Glucose Tolerance Test and MRI Pituitary
First-line Treatment Trans-sphenoidal Pituitary Surgery

Headache Red Flags

Morning headache Visual deterioration Bitemporal hemianopia Diplopia / III nerve palsy Pituitary apoplexy Urgent endocrine / neurosurgical referral

PACES Approach

① Characterise the headache ② Ask about visual symptoms & endocrine features ③ Examine face, hands, feet and visual fields ④ Confirm Acromegaly due to pituitary adenoma ⑤ Explain diagnosis, treatment and follow-up

Overview

Acromegaly is usually caused by a growth hormone-secreting pituitary adenoma. In PACES, patients often present with progressive headache, enlarging hands and feet, coarse facial features, visual disturbance or complications related to excess growth hormone. Candidates should recognise the characteristic phenotype, identify symptoms of pituitary mass effect, perform a focused examination including visual fields, and explain the diagnosis and treatment clearly. The diagnosis is confirmed biochemically with an elevated IGF-1 level and failure of growth hormone suppression during an oral glucose tolerance test, followed by MRI of the pituitary gland. :contentReference[oaicite:0]{index=0}

Structured History

  • Characterise the headache (onset, duration, progression)
  • Morning headache or headache waking from sleep
  • Visual disturbance or loss of peripheral vision
  • Diplopia or cranial nerve symptoms
  • Increase in shoe, glove or ring size
  • Change in facial appearance noticed by family
  • Excessive sweating or oily skin
  • Joint pain, back pain or carpal tunnel symptoms
  • Reduced libido, erectile dysfunction or menstrual disturbance
  • Symptoms of diabetes, hypertension or sleep apnoea

Examination

  • Coarse facial features
  • Frontal bossing
  • Prominent jaw (prognathism)
  • Macroglossia
  • Large hands and feet with spade-like fingers
  • Thick oily skin
  • Visual field assessment for bitemporal hemianopia
  • Blood pressure and cardiovascular examination
  • Examine joints for osteoarthritis
  • Look for features of associated endocrine disease

Differential Diagnosis

Pituitary macroadenoma Gigantism Hypothyroidism Paget disease Acromegaloidism Pseudoacromegaly Familial coarse facial features Medication-related headache

Investigations

  • Serum IGF-1 level (

    Diagnosis

    Acromegaly secondary to a Growth Hormone-Secreting Pituitary Adenoma

    The diagnosis is suggested by progressive headache, enlarging hands and feet, coarse facial features, visual field defects and symptoms of growth hormone excess. Confirmation is by elevated IGF-1, failure of GH suppression during an Oral Glucose Tolerance Test and MRI of the pituitary.

    Management

    First-line Treatment Trans-sphenoidal Pituitary Surgery
    Medical Therapy Somatostatin analogues, Pegvisomant or Dopamine agonists
    Long-term Follow-up IGF-1 monitoring, MRI surveillance and management of complications

    Explaining to the Patient

    "Your symptoms are most likely due to a small growth in the pituitary gland producing excess growth hormone. This causes gradual changes in your appearance and may also explain your headaches and visual symptoms. Treatment usually involves surgery to remove the tumour, although medication and occasionally radiotherapy may also be needed. Most patients continue long-term follow-up with an endocrinologist."

    Examiner's Corner

    Common Viva Questions
    • What causes Acromegaly?
    • How is Acromegaly diagnosed?
    • Why is an Oral Glucose Tolerance Test performed?
    • What complications occur if untreated?
    • How is Acromegaly treated?
    • What causes the visual field defect?
    • What is Pituitary Apoplexy?
    Complications of Acromegaly
    Hypertension Diabetes Mellitus Cardiomyopathy Heart Failure Obstructive Sleep Apnoea Carpal Tunnel Syndrome Osteoarthritis Colorectal Polyps
    Pituitary Apoplexy
    • Sudden severe headache
    • Visual loss or ophthalmoplegia
    • Hypotension due to acute pituitary failure
    • Requires urgent corticosteroids
    • Urgent neurosurgical assessment
    Important Investigations
    • IGF-1
    • Growth Hormone after Oral Glucose Tolerance Test
    • MRI Pituitary
    • Visual field assessment
    • Assessment of other pituitary hormones
    • Screening for diabetes and hypertension

    Pathfinder Pearls

    Compare old and recent photographs Ask about increasing shoe and ring size Always examine visual fields Think pituitary adenoma first Remember sleep apnoea Screen for diabetes & hypertension Know Pituitary Apoplexy Trans-sphenoidal surgery is first-line

    Common Pitfalls

    • Not assessing visual fields.
    • Ignoring symptoms of pituitary apoplexy.
    • Forgetting to ask about change in shoe or ring size.
    • Missing diabetes, hypertension or sleep apnoea.
    • Not examining the hands and jaw carefully.
    • Failing to assess other pituitary hormone deficiencies.
    • Using GH instead of IGF-1 as the initial screening test.

    Master MRCP (UK) PACES with PACES Pathfinders

    Join our structured online PACES programme covering presenting complaints, communication stations and short cases through interactive teaching, examiner-focused discussions, mock stations and recorded sessions.

    View Current Course Join via WhatsApp