Migraine Headache
Age: years old
Gender:
HISTORY:
Presents with a - history of
Onset was , and occurred
Location is , on the
Radiation to
Rated at / 10
Described as
Pattern , worse during the
Worsening factors:
Alleviating factors: ,
Associated symptoms: *Try using right-click for negatives*
, episodes , ,
Contributing factors:
no history of: ,
no family history of:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head: , scalp
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Cervical spine: on , range of motion
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought , , judgment
ASSESSMENT:
DDx: migraine, tension-type headache, cluster headache, medication overuse headache, sinusitis, temporomandibular joint disorder, giant cell arteritis, subarachnoid hemorrhage, meningitis, encephalitis, brain tumor, intracranial hemorrhage, pseudotumor cerebri, glaucoma, hypertension, caffeine withdrawal, dehydration
PLAN:
Investigations:
- CT scan of the head
- MRI of the head
- Blood work: , , ,
Treatments:
-
-
-
-
-
- Avoid medication overuse (more than 10 days per month) to prevent rebound headaches
- Avoidance of triggers (e.g. caffeine, alcohol, stress)
- Regular exercise
- Stress management techniques
- Good sleep hygiene
Further care:
- Referral to neurologist
- 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
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: