When it’s not just stomach ache: exam anxiety in school pupils

GCSE and A-level exams are officially underway. For many pupils and students, exam season brings a manageable level of stress that passes once results are in. But for others, the pressure of exams builds into something more significant than pre-test nerves.

Stomach aches before school. Headaches that keep coming back. Frequent visits to the first aid room, but no apparent physical causes. These are patterns that school staff will recognise, and during exam season, they can become more common.

Anxiety in children and teens doesn't always look the way we might expect. It doesn't always present as visible worry or tearfulness. Often, it shows up in the body first, as physical complaints that are very real, even when there is no medical cause behind them.
Recognising the signs, responding appropriately, and knowing when to escalate have become increasingly important aspects of staff responsibilities.

Exam anxiety appears to have become a regular feature of school life, making it one of the most common things staff encounter during this period and one of the most important to understand.

❗ Referrals for children and young people where the primary concern is anxiety more than doubled between the year before Covid and 2023-24, rising from just under 99,000 to over 204,000. (NHS England)

❗ 96% of young people say mental health affects their schoolwork. (CPD Online College)

❗Exam anxiety is overwhelming in secondary schools. Around 99% of secondary teachers report seeing exam anxiety in students. Of these, 72% say they see it regularly. (National Education Union)

In this week’s issue of The First-Aid Room, we explore what anxiety can actually look like during exam season, how staff can respond when a student presents with symptoms, and when it may be appropriate to involve additional support.

Why exam anxiety shows up in the body

When we feel stressed, the nervous system activates a stress response designed to protect the body from danger. Even without a real threat, this response can trigger genuine physical sensations. Children are especially sensitive to these changes, so emotional pressure can quickly translate into physical discomfort.

During exams, this sensitivity is heightened. Symptoms such as stomach aches or headaches are rarely imagined; they are real experiences, even when no medical cause is found.

Common physical symptoms of exam anxiety in pupils include:

• Stomach aches or nausea, particularly on exam days or the morning before school
• Headaches
• Feeling lightheaded or dizzy
  
• Sweating
• Fatigue or difficulty sleeping in the lead-up to exams
• A racing heart or feeling shaky
• Pale or clammy skin – changes may be less visible on darker skin tones
• General anxiety symptoms (increased heart rate, , feeling ‘butterflies’)
  
• Panic attacks

Pupils may not even know they are anxious and may struggle to verbalise what they are feeling, so anxiety can manifest through physical symptoms before any emotional distress is expressed.

Anxiety can also be detrimental to pupils' ability to perform during exams – they may be unable to focus on the exam or retain information studied, feel like their "mind goes blank", use unhealthy coping strategies to deal with nerves, or skip classes or exams due to fear.

There are several reasons exam anxiety can arise:

• Fear of failure
• Perfectionism
• Pressure to reach a desired grade
• Pressure from parents/caregivers, family and teachers
• Lack of preparation
• Previous negative experiences of exams
• Worry about future study or career opportunities

Recognising exam anxiety in the first aid room

Patterns matter. A one‑off stomach ache is normal. But repeated visits that coincide with exams, certain subjects, or revision periods may indicate exam-related anxiety.

Below are some indicators that physical symptoms may be anxiety-driven:

• Symptoms appear before specific exams or high‑pressure moments
• Symptoms ease once the stressful event has passed
• No physical cause is found after repeated checks
• Behavioural changes accompany symptoms: withdrawal, irritability, difficulty concentrating
• Visits increase as the exam timetable progresses

The exam window compresses academic pressure into a short, intense period, and not all pupils have the coping tools they need.

How to respond when a pupil presents with symptoms

When a pupil comes to you with physical symptoms during exam season, the way you respond matters enormously.

What you can do:

✅ Take the symptoms seriously and acknowledge that the discomfort is real
✅ Create a calm, low-pressure environment
✅ Allow a short rest break, but aim to support a return to the exam or classroom rather than sending the pupil home where possible
✅ Ask open, gentle questions: for example, you could ask: "Is there anything about today that feels particularly difficult?"
✅ Let the pupil know who they can talk to if they need support

What you should avoid:

❌ Dismissing symptoms or suggesting they are "just nerves"
❌ Putting pressure on the pupil to explain or justify how they are feeling
❌ Inadvertently reinforcing avoidance by making it more comfortable to stay out of the exam hall than to return

Short breaks are better than missing an exam entirely: as much as possible, the aim should be to support the pupil back into the situation rather than removing them from it altogether.

When to escalate

School staff are not expected to diagnose mental health conditions or perform mental
health interventions, but they are required to ensure regular attendance for every child. Not all exam anxiety will require referral, but some pupils may benefit from additional support.

Staff should escalate concerns when:

👉 Physical symptoms are persistent, severe, or escalating across the exam period
👉 A pupil's anxiety is significantly affecting their ability to sit exams or attend school
👉 There are signs of self-harm, low mood, or significant distress
👉 A pupil discloses that they feel unsafe, or there are safeguarding concerns

Staff can report concerns and liaise with the Designated Safeguarding Lead (DSL) and SENCO, as anxious behaviour may indicate emerging mental health difficulties.

The escalation pathway in schools can look like this:

1. Class teacher or first aider: initial observation and response
2. Form tutor or head of year: pattern monitoring and pastoral support
3. SENCO or designated mental health lead: structured support plan
4. External referral: GP, Early Help, or CAMHS where needs exceed what the school can provide

Schools should have clear systems and processes to help staff identify children with possible mental health problems, with routes to escalate issues through clear referral and accountability systems.

💡 Good to know: Medical Tracker now integrates with CPOMS Systems. Opening a digital pathway from Medical Tracker to CPOMS allows schools to create a holistic healthcare provision encompassing first aid, physical, mental, safeguarding, and wellbeing support. 

Supporting pupils through exam season: a whole-school responsibility

While school counsellors and SENCOs play an important role, a whole-school approach to promoting good mental health can be the most effective way to support pupils during exam periods.

Simple, consistent practices across the school make a real difference during the exam period:

✅ Promote a calm, predictable exam environment (consistent routines, clear expectations)
✅ Encourage conversations about exam stress so pupils feel it is normal and manageable
✅ Identify and support pupils who may be more vulnerable (for example, those with prior anxiety or poor exam experiences)
✅ Reinforce positive coping strategies
✅ Ensure all staff know the signs of exam anxiety and feel confident responding calmly
✅ Create clear, low-pressure routes for pupils to access support during the exam period
✅ Know your school's referral and escalation pathway before it is needed
✅ Keep parents and carers informed and involved early, particularly where concerns are growing
✅ Ensure reasonable adjustments are considered where appropriate and in line with school policy

A stomach ache on exam morning might just be a stomach ache. But it might also be a student telling you that something isn't right. The more confident staff feel in recognising and responding to that, the better placed the whole school is to support pupils through one of the most pressured periods of their school lives.

Supporting resources

1. Staff Quick Guide – Recognising and Responding to Exam Anxiety
2. Student wellbeing card – Feeling overwhelmed by exams? You're not alone. (A6)
   
3. Parent Guidance - Exam Anxiety (brochure)