Headache/Migraine Clinic Note

Date: [Date] | Patient: [Patient name or identifier] | Visit Type: [new consult / follow-up] | Provider: [Provider name, credentials] | Location: [in-person / telehealth] | Last Visit: [Date] (Only include Last Visit if follow-up)

History

Chief Complaint: [One-line in patient's words when clarifying; otherwise concise summary]

Identifying Statement: [One sentence with age, key comorbidities, and presenting headache problem]

Interval Context: [Monthly headache days since last visit with trend, acute medication-use days per month, change in functional impact] (Include only for follow-up visits)

Headache Characterization: (Repeat for each distinct headache type if more than one pattern)

• Headache type: [Label or pattern description]
• Onset and course: [Age at onset; episodic vs chronic pattern per ICHD-3 thresholds]
• Frequency/duration: [Days per month; typical duration untreated and treated]
• Character: [Location, quality, severity with numeric scale and functional impact]
• Associated features: [Nausea, photo/phonophobia, aura features if present, autonomic symptoms if present]
• Modifying factors: [Key triggers and relievers]
• Pivotal descriptors: [Brief direct quote if thunderclap or other pivotal feature, with clinical translation including time-to-peak] (Include only if present)

Disability/Impact: [HIT-6 / MIDAS / PedMIDAS score with date; missed work/school days and partial-function days with timeframe; effect on ADLs]

Current Medications:

• Acute: [Each medication with dose, route, actual use pattern in days per month]
• Preventive: [Each medication/intervention with dose and adherence]

Prior Treatment Trials: [Acute and preventive trials with max dose, duration, response, adverse effects, reason stopped] (If details uncertain, document that history is limited and will be verified)

Red-Flag Screen:

• Systemic symptoms/immunosuppression: [positive / negative / not assessed]
• Sudden/thunderclap onset: [positive / negative / not assessed]
• Neurologic deficits: [positive / negative / not assessed]
• Progressive worsening: [positive / negative / not assessed]
• Papilledema: [present / absent / not assessed]
• Positional/exertional features: [present / absent / not assessed]
• Recent head/neck trauma: [yes / no / not assessed]
• Pregnancy/anticoagulation: [status or not applicable / not assessed] (Include when clinically relevant)

(Do not auto-populate negatives for items not evaluated; document "not assessed" for any safety-critical item not evaluated)

Examination

Vitals: [Blood pressure, pulse, and other vitals as relevant]

General: [Appearance, distress level]

Neurologic Exam: [Mental status, cranial nerves, motor, sensory, coordination, gait findings; document "not assessed" for any element not performed]

Fundoscopic Exam: [Findings / not assessed]

Cervical Exam: [ROM, tenderness] (Include if cervicogenic features considered; otherwise omit)

(For telehealth encounters, explicitly note exam limitations)

Data Reviewed: [Imaging, labs, prior notes, headache diary, and PROMs reviewed with dates and key findings] (Label patient-reported results as unverified)

Assessment

(Number problems in descending clinical importance; use ICHD-3 terminology; include medication-overuse headache as separate diagnosis if criteria met; note differentials when diagnosis not established)

1. [Diagnosis 1]: [1–2 key supporting features; differential if applicable]
2. [Diagnosis 2]: [Key supporting features] (Include additional diagnoses as needed)

Imaging Rationale: [Ordered or deferred and clinical reasoning]

Plan

Acute Treatment: [First-line medication with dose, route, timing instructions; antiemetic if needed; rescue plan for refractory attacks; maximum monthly use limits to reduce overuse risk]

Preventive Treatment: [Medication/intervention with rationale; titration schedule and expected time to benefit; monitoring plan; nonpharmacologic strategies as applicable; criteria for success]

Lifestyle & Education: [Counseling topics addressed; patient-specific action items; school/work accommodations if discussed]

Follow-Up: [Interval; data to bring including headache-day counts, medication-use days, PROM score; earlier return triggers]

Return Precautions Reviewed: [yes, patient verbalizes understanding / no, not reviewed] (Precautions include: sudden severe headache peaking rapidly, new neurologic deficits, confusion or seizure, fever with neck stiffness, persistent vomiting, headache distinctly different from usual)

Time-Based Billing: [Total clinician minutes] (Include only if billing by time)