Headache/Migraine Clinic Note

Date: [encounter date]

Patient: [name, age, sex]

Encounter Type: [new / return]; [in-person / telehealth]

Clinician: [name and role]

Referring Provider: [name and role] (Only include if applicable)

Chief Complaint

[Patient-stated reason for visit with current frequency if known] (May include a brief direct quote if it clarifies framing.)

History of Present Illness

Headline Summary: [Current headache phenotype(s)]; [trajectory: improved / worsened / stable]; [frequency metrics: headache days/month and migraine days/month]; [key interval changes: new symptoms, ER visits, medication changes, pregnancy status if relevant]. (Limit to 2–3 sentences.)

Phenotype Characterization

(For each distinct headache type, include a separate entry. If only one stable phenotype with no interval change, abbreviate to metrics only.)

• [Headache type]: [Onset and evolution]; [attack duration untreated and treated]; [pain quality and location]; [intensity and functional impact]; [associated features: nausea, photophobia, phonophobia, aura characteristics, cranial autonomic symptoms]; [temporal pattern]; [response to acute medications].

Headache Frequency Metrics

Measurement window: [e.g., past 30 days]

• Headache days/month: [number]
• Migraine days/month: [number]
• Average duration per attack: [hours]
• Morning or wake-from-sleep headaches: [yes / no / unknown]
• Tracking method: [diary / recall / app]

Triggers and Modulators

[Relevant triggers and modulators identified] (Include only clinically meaningful factors such as sleep irregularity, stress, hormonal/menstrual factors, caffeine patterns, exertion. Omit section if none identified.)

Red Flag Screen

(Document pertinent positives and negatives. This section is safety-critical; if not assessed, state "not assessed." If any item is positive, include Secondary Headache Consideration below.)

• Thunderclap/first-worst onset: [present / absent / not assessed]
• New focal neurologic symptoms: [present / absent / not assessed]
• Fever/meningismus: [present / absent / not assessed]
• Immunocompromised state: [present / absent / not assessed]
• Papilledema symptoms: [present / absent / not assessed]
• Positional or Valsalva-triggered headache: [present / absent / not assessed]
• Recent head or neck trauma: [present / absent / not assessed]
• Progressive pattern change: [present / absent / not assessed]
• Pregnancy/postpartum: [pregnant / postpartum / not pregnant / not applicable] (Include when relevant.)

Secondary Headache Consideration

(Include only if any red flag is positive.)

[Suspected secondary etiologies]; [workup plan]; [safety instructions provided].

Disability Assessment

[Formal instrument score with category and timeframe, or narrative functional impact including missed work/school, ED utilization, quality of life]

Prior Workup

(Include only if relevant to current assessment.)

• [Study type, date, and impression]

Medications

Current Acute Regimen

• [Medication]; [dose and route]; [timing: at onset / delayed]; [use frequency]; [effectiveness: complete / partial / ineffective]; [adverse effects].

Current Preventive Regimen

• [Medication or therapy]; [dose]; [duration on therapy]; [adherence]; [tolerability]; [perceived benefit].

Acute Medication Days/Month

(Required for medication overuse assessment. If unknown, state "unknown—will obtain via diary or pharmacy records.")

• Simple analgesics/NSAIDs: [days/month]
• Triptans/gepants/ditans: [days/month]
• Combination analgesics: [days/month]
• Opioids: [days/month]
• Ergots: [days/month]

Prior Treatment Trials

• [Medication]; [max dose]; [duration]; [outcome: effective / partial / ineffective]; [reason stopped]; [adequate trial: yes / no].

Relevant History

[Focused history relevant to headache management: psychiatric comorbidities, sleep disorders, cardiovascular disease, kidney/liver disease, pregnancy status/intention, family history of migraine or aneurysm/SAH if relevant]

Physical Examination

• Vitals: [BP, HR] (Blood pressure particularly relevant.)
• General: [Appearance and level of distress]
• Head/Neck: [Cervical ROM, occipital/temporal tenderness]
• Neurologic: [Mental status, cranial nerves, motor, sensory, reflexes, coordination, gait]
• Fundoscopic: [Findings] (Include if red flags or IIH concern; otherwise state "not performed.")

Data Reviewed

(Include only if outside data reviewed.)

• [Study or record type, date, interpretation, independent review: yes / no]

Assessment

(Problem list ordered by clinical priority. For each diagnosis: state working diagnosis with qualifiers, 1–2 supporting features, and severity/disability statement. List coexisting diagnoses separately. Note contributing factors.)

[Problem 1]: [Diagnosis with qualifiers]

• Supporting features: [1–2 key features]
• Severity/disability: [brief statement]
• Contributing factors: [if applicable]

[Problem 2]: [Additional diagnosis]

(Include additional problems only if applicable.)

Neuroimaging not indicated: [No red flags present, normal neurologic examination, stable phenotype.] (Include only when supported by documented findings.)

Plan

Acute Treatment

• First-line: [Medication, dose, route]; take at onset.
• Second-line: [Medication, dose]; [timing relative to first-line].
• Rescue: [Strategy for severe/prolonged attacks].
• Antiemetic: [Medication, dose] (Include if nausea limits oral therapy.)
• Use limits: [Maximum daily dose]; [monthly limits by class to prevent medication overuse].

Preventive Treatment

• Rationale: [Brief justification]
• Medication: [Name]; [starting dose]; [titration schedule]; [expected time to benefit].
• Monitoring: [Labs, vitals, side effect screening]; [reassessment interval].
• Success criteria: [e.g., ≥50% reduction in migraine days].

Non-Pharmacologic

[Lifestyle interventions, physical therapy if cervicogenic component, behavioral therapy referrals] (Include only relevant interventions.)

Safety Net

Return precautions reviewed: [thunderclap onset, new neurologic deficits, fever with neck stiffness, vision changes, persistent vomiting, head trauma, severe headache in pregnancy/postpartum].

Follow-Up

Timeframe: [e.g., 6–8 weeks after preventive initiation]

Tracking instructions: [Headache days, migraine days, acute medication days, side effects via diary or app]