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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