headache

onset

hours days weeks months years

new?

new issue known/chronic issue

intensity

mild mild-moderate moderate moderate-severe severe

frequency

single episode constant intermittent daily few times a week few times a month

duration

few minutes less than an hour few hours most of the day few days

status

improving unchanged resolved gradually worsening significant worsening

context

head trauma yes no

location

entire head frontal left frontal right ocular left ocular right
parietal left parietal right temporal left temporal right occipital vertex

radiation

none anterior posterior neck shoulders

quality

blinding debilitating dull pressure superficial sharp throbbing squeezing stabbing
worst ever

timing

daytime menstrual periods upon awakening evening

aggravated by

nothing head position/movement anxiety allergies bright lights caffeine exercise foods noise stress valsalva weather

relieved by

nothing dark massage sleep position stretching relaxation caffeine OTC meds
prescription meds

other/negatives

inspection

normal

palpation

normal

neck

CN exam

normal

snellen

not tested
L 20/20 20/25 20/30 20/40 20/50 20/70 20/100 20/200
R 20/20 20/25 20/30 20/40 20/50 20/70 20/100 20/200

other

Assessment:

migraine concussion tension cluster

red flags

no red flags

imaging

no indication indicated

details

Plan:

medication

tylenol/NSAIDs triptans opioids
prophylactic

behavioural

headache diary lifestyle stress

imaging

CT MRI

referral

neurology optometry ophthalmology

off work

yes (1-2 weeks) no

follow-up

2-4 weeks PRN only

RTC

instructions given

other

HEADACHE:

S/

O/

A/

P/