Headache
HISTORY:
Headache for
Onset: , following
Location:
Radiation:
Severity: / 10 ,
Type:
Pattern: , worse during the
Episode duration:
Frequency: times per
Worsening factors or triggers:
Treatments tried: ,
Analgesics use: days per month
Additional symptoms:
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head:
Eyes: -R: , -L: ,
Ears: -R: , -L:
Neck:
Heart: ,
Lungs: ,
Cervical spine: on , range of motion
Neurologic:
- Mental status: , oriented in , speech
- Cranial nerves:
- Strength: upper extremities -R /5 , -L /5
lower extremities -R /5 , -L /5
- Sensation: upper extremities -R , -L ,
lower extremities -R , -L
- Reflexes: triceps -R , -L , biceps -R , -L , brachioradialis -R , -L
patellar -R , -L , achilles -R , -L , plantar -R , -L
- Cerebellar function: , finger-nose , rapid alternating movements , heel-knee , Romberg , Dix-Hallpike ,
- Gait: , tandem walking , heel and toe walking
ASSESSMENT:
DDx:
PLAN:
- CT scan of the brain
- MRI of the brain
- Blood work: , , ,
-
-
-
- Regular exercise
- Stress management techniques
- Sleep hygiene
- Avoidance of triggers (e.g. caffeine, alcohol, stress)
- Avoidance of overuse of analgesics
- Referral to neurologist
- Referral to psychologist
- Follow-up in
- Return if headaches worsen, if new symptoms develop such as vision changes or weakness, or if symptoms do not improve with treatment