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Headache Evaluation Note Headache History - Onset age, attack frequency (days/month), duration, intensity (0–10), and location/laterality. - Quality (throbbing, pressure, stabbing), aura (visual/sensory/speech), associated symptoms (nausea, photophobia, phonophobia, osmophobia, autonomic features). - Triggers, menstrual association, and circadian pattern. - Disability impact (work/school missed; MIDAS or HIT-6 if obtained). Red Flags / Secondary Features - Sudden/thunderclap onset, neurologic deficit, fever/neck stiffness, cancer/immunosuppression, pregnancy, trauma, progressive pattern, positional change, or age >50 with new headache. - Document presence or absence of concerning features discussed. Current & Prior Treatments - Acute medications (dose, frequency, response) and monthly acute-medication days. - Preventives tried with dose, duration, benefit, and reasons stopped. - Risk of medication-overuse headache. Exam - Vitals; focused neurologic exam including fundoscopic exam if performed. - Relevant musculoskeletal or sinus findings if assessed. Data Reviewed - Prior imaging, LP, labs, or headache diary data as discussed. Assessment - Headache diagnosis (e.g., migraine without aura, chronic migraine, TTH, MOH, cluster) and secondary-headache risk assessment. Plan - Acute treatment strategy and limits to avoid overuse. - Preventive therapy initiation/changes and expected timeline to benefit. - Lifestyle counseling, imaging if indicated, referrals, and follow-up. - Return precautions for red-flag symptoms.
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Best for
Visit types and clinicians who use this format
- Separates migraine features, secondary-headache red flags, and medication overuse risk.
- Captures disability (MIDAS/HIT-6) when discussed without forcing unused scores.
- Supports acute and preventive plans in one assessment/plan block.
- Useful starting point for AI specialty templates in headache-focused practices.
- 1New headache or migraine consultations
- 2Complex headache follow-ups with regimen redesign
- 3Medication-overuse headache evaluations
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Headache History 32-year-old with headaches since teens, now 12 headache days/month for 8 months. Attacks are unilateral throbbing, 7/10, with nausea and photophobia; occasional visual zig-zag aura ~20 minutes. MIDAS 18. Triggers include menses and poor sleep. Red Flags No thunderclap, fever, focal deficit, or progressive daily continuous pattern. Neurologic exam nonfocal previously; none today. Treatments Uses sumatriptan 100 mg ~10 days/month with good relief; ibuprofen other days. Failed topiramate for cognitive side effects. Not on current preventive. Exam BP 118/70. Alert, CN intact including pupils; fundi sharp. No focal motor/sensory deficit. Neck supple. Assessment Chronic migraine without aura; high acute-medication days concerning for emerging MOH risk. No secondary red flags today. Plan Start candesartan 4 mg daily, titrate per protocol. Limit triptan/NSAID to ≤2 days/week when possible; consider gepant bridge education. Sleep and trigger diary. No imaging indicated today. Follow up 8 weeks; ED for thunderclap, focal deficit, or fever with stiff neck.
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