headache_clinic_template.md 5.69 KB
headache neurology outpatient template v1

HPI

name:
age:
handedness:
CC referral:
CC patient:

how many types of headaches?

headache characterization

headache #____

  • onset
  • location
  • severity (now, maximum, average)
  • quality
  • course/evolution (e.g. time to maximal intensity, remits?)
  • exacerbating factors
    • light
    • sound
    • smells
    • position (standing vs. supine)
  • triggering factors:
    • sleep, diet/foods, weather
    • valsalva / sneezing / cough / bowel or bladder movements
    • for women: menstruation
  • associated symptoms
    • nausea / vomiting
    • vision changes (bright or dark spots or vision loss before/during?)
    • focal sensorimotor symptoms or other focal neuro deficits
    • vasomotor symptoms (running nose, watery eyes, red eye)
  • alleviating factors
  • remember exact day/time headache started?
  • waking up at night because of headache

(repeat above for each headache)

modifying factors re all headaches

  • caffeine intake (specifically ask re coffe, tea, soda, bc powder)
  • sleep
  • fluid intake
  • diet/skipping meals
  • stressful life events / changes

medicines for headaches or other pain

  • for each med: dose, frequency, start of use, evolution/course of use, benefit?

current acute-tx/abortive medicines

 

current prophylactic-tx medicines

 

prior meds for headaches or other pain

 

  • as above

prior headache workup

  • prior diagnoses relating to headaches (e.g. migraine, tension headache?)
  • ever head neuroimaging: MRI (?contrast) or CT

ROS

  • motion sickness
  • dizziness / vertigo
  • snoring / apneic events at night

PMHx

migraine diagnosis       sleep apnea       psychiatric comorbidities (depression / anxiety )       stroke       seizure       head-trauma       meningitis       HTN       DM       HLD       a-fib/heart-dz

 
 
 
 

meds

 
 
 
 

SHx

EtOH:
tobacco:
illicit drugs:
occupation:
married/prior-marriages:
living location/situation:

FHx

headaches specific headache d/o dx by neurologist/MD (e.g. migraine) dad:
mom:
siblings:
children:

Exam

weight / BMI:
CV:
Resp:
Ophtho:

Neuro:
MS:
CN:
Mot:
Sens:
Refl:
Coord:
Gait:

Labs/Studies

MRI:

Impression

Formulation:
[age] year-old [R/L]-handed [man/woman] presents with [chief complaint]. Exam notable for [notable exam elements]. Studies notable for [notable studies]. Localization includes: [localization differential if applicable from cortex to muscle vs. e.g. diffuse].

Differential includes:

primary headache disorders

migraine

  • criteria for w/o aura:

    • at least 5 episodes meeting the following criteria, w/o another better diagnostic etiology
    • duration of 4-72 hours (untreated or unsuccessfully treated)
    • 2 of the following characteristics:
      • unilateral
      • pulsating
      • moderate to severe pain intensity
      • aggravated by, or causing avoidance of, routine physical activity
    • during headache one of the following:
      • nausea or vomiting
      • photophobia and phonophobia
  • criteria for w aura:

    • at least 2 episodes meeting following criteria, w/o another better diagnostic etiology & with exclusion of TIA
    • at least one of the following fully-reversible aura symptoms
      • visual
      • sensory
      • speech and/or language
      • motor
      • brainstem
      • retinal
    • for qualification of TYPICAL aura: fully reversible visual, sensory, and/or speech/language symptoms - without motor, brainstem, or retinal symptoms
    • 2 of following:
      • one aura symptom spreads gradually over >=5 min OR two or more symptoms occurring in succession
      • each individual aura lasting 5-60 min
      • at least one aura symptom unilateral
      • headache accompanying aura OR following within 60 min

tension

  • criteria require the following

    • 2 of:
      • bilateral location
      • quality pressing/tightening (non-pulsating)
      • mild/moderate intensity
      • not aggravated by routine physical activity (e.g. walking or stair-climbing)
    • both of:
      • no nausea or vomiting
      • no more than one of photophobia or phonophobia
  • episodic type: at least 10 episodes lasting 30min to 7days

  • chronic type: hours to days or unremitting, >=15 days/month on average for more than three months (>=180 days per year)

cluster

new daily persistent headache

  • dx criteria:
    • distinct & clearly remembered onset, with pain becoming continuous and unremitting within 24 hrs
    • present/persistent for at least three months
    • another diagnosis does not better explain
  • rule out secondary causes
  • may have migrainous or tension features

secondary headache disorders

  • medication-induced/associated
  • pseudotumor
  • cervicogenic
  • low CSF
  • chronic meningitis
  • mass lesion

Plan

further workup (if indicated)

  • neuroimaging
  • labwork

treatment

  • acute treatments
    • NSAIDS - use no more than 2x/week
    • triptan
  • prophylactic treatments
    • cyproheptadine
    • topiramate
  • modifying / lifestyle factors
    • avoid caffeine overuse
    • maintain regular sleep schedule
    • fluid intake
    • eat regular meals without skipping meals

rtnv (time frame?)?

references:

  • The International Classification of Headache Disorders 2013 - doi: 10.1177/0333102413485658
  • UpToDate: Pathophysiology, clinical manifestations, and diagnosis of migraine in adults. accessed 2/2017
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