Headache Biofeedback Session Note (Migraine/Tension-Type)

Date of Service: [date]

Patient: [name, DOB, MRN]

Session: [ordinal of total planned / booster]

Headache Type(s) Targeted: [migraine / tension-type / mixed]

Rendering Clinician: [name, credentials]

Session Focus

[Purpose and biofeedback training focus for today's session] (Limit to 1–2 sentences. Note any deviation from the planned session such as arrival in active headache.)

Subjective

Interval Headache Status: [headache days, intensity ratings, acute medication days, functional impact over tracked timeframe] (Document over the past 7 or 28 days as tracked. Note any pattern changes or new symptoms. If no diary data, record patient estimates and explicitly note the limitation.)

Triggers & Context: [relevant exposures since last session] (Include only factors actually reported: sleep, stress, caffeine, hydration, posture, screens, hormonal context, etc.)

Home Practice Adherence: [what was prescribed vs. what was completed] (Specify frequency, duration, and days completed. Briefly note barriers or facilitators if relevant.)

Regimen Updates: [new or changed medications, supplements, or other treatments] (If clinician is not the prescriber, document as observation/coordination rather than recommendation. Omit if no changes.)

Safety Screen: [No red-flag features endorsed. / red-flag features and actions taken] (Always include. If pattern changed, assess for thunderclap onset, neuro deficits, positional features, systemic symptoms.)

Objective

Biofeedback Setup: [modality: sEMG / thermal / HRV / combination]; [sensor placement]; [patient position]; [environment modifiers]; [signal quality] (Note any calibration issues or artifact.)

Session Metrics: [baseline values, training block results with targets, recovery/generalization performance using modality-appropriate metrics] (For sEMG: site and µV values. For thermal: site and temperature change. For HRV: respiration rate, HR, and device-reported HRV metric by name. Include pre/post subjective ratings for pain and tension (0–10) when obtained. Document measurement failures rather than leaving blank.)

Skills Practiced: [techniques trained and physiologic response] (e.g., diaphragmatic breathing, progressive muscle relaxation, autogenic imagery, jaw/shoulder release cueing, cue-controlled relaxation.)

Assessment

Session Response: [target physiologic direction achieved: yes / partial / no]; [effective coaching strategies]; [tolerance of provocation/generalization tasks]; [adverse effects if any]

Progress Toward Goals: [quantified comparison to prior sessions and care plan goals] (Reference documented metrics only. Do not claim improvement without documented evidence.)

Plan

Next Session: [planned modality]; [target focus]; [progression intent]

Home Practice: [technique]; [duration]; [frequency]; [timing]; [cueing prompts]; [what to track] (Write in prescription style with clear adherence targets.)

Lifestyle Adjustments: [specific, feasible recommendations tied to today's findings] (Include only if directly relevant; limit to 1–3 items. Omit if none indicated.)

Coordination: [updates sent or planned to neurologist/PCP/PT; requests for medication review] (Document patient permission. Omit if no coordination needed.)

Follow-up: [next appointment date or scheduling plan]; [remaining sessions]; [discharge criteria if relevant]