EHR Template for Migraine Evaluation
An effective EHR template for migraine evaluation must systematically capture diagnostic criteria, attack characteristics, disability measures, medication use patterns, and red flags for secondary headaches to enable accurate diagnosis and treatment monitoring. 1
Essential Components for Initial Evaluation
Patient Demographics and History
- Age at migraine onset (typically at or around puberty strengthens diagnosis)
- Family history of migraine (strong genetic component; prevalence higher among first-degree relatives)
- Duration of headache disorder 1
Attack Characteristics (Required for ICHD-3 Diagnosis)
The template must capture specific features to apply International Classification of Headache Disorders criteria 1:
Headache Features:
- Frequency: Number of headache days per month (≥15 days = chronic migraine)
- Duration: Length of individual episodes
- Location: Unilateral vs bilateral
- Quality: Pulsating vs non-pulsating
- Severity: Mild, moderate, or severe intensity
- Aggravating factors: Physical activity, postures that raise intracranial pressure
Accompanying Symptoms:
- Photophobia (sensitivity to light - most frequently reported bothersome symptom) 2
- Phonophobia (sound sensitivity)
- Nausea and/or vomiting
- Cognitive dysfunction (when present, most frequently the most bothersome symptom) 2
Aura Symptoms (if present):
- Visual disturbances (recurrent, short-lasting)
- Hemisensory disturbances
- Duration and characteristics 1
Red Flags Assessment (Critical for Ruling Out Secondary Headaches)
The template must include structured screening for dangerous secondary causes 1:
From Patient History:
- Thunderclap headache (subarachnoid hemorrhage)
- Atypical aura (TIA, stroke, epilepsy, arteriovenous malformations)
- Recent head trauma (subdural hematoma)
- Progressive headache pattern (space-occupying lesion)
- Headache worsened by postures/maneuvers raising intracranial pressure
- Headache triggered by sneezing, coughing, or exercise
- Associated weight loss, memory changes, or personality changes
- New onset at >50 years of age (consider temporal arteritis)
Physical Examination Findings:
- Unexplained fever (meningitis)
- Neck stiffness (meningitis, subarachnoid hemorrhage)
- Focal neurological symptoms
- Papilledema (on focused exam) 3
- Muscle spasm or allodynia 3
Disability and Impact Measures
Validated outcome measures must be integrated 1:
- MIDAS score (Migraine Disability Assessment) - captures attack frequency, severity, and disability
- mTOQ-4 (Migraine Treatment Optimization Questionnaire) - evaluates acute medication effectiveness at follow-up 1
- HURT questionnaire (Headache Under-Response to Treatment) - 8-item self-administered tool assessing treatment effectiveness with management suggestions 1
Medication Documentation
Current and Historical Use:
- Acute medications: Specific agents, frequency of use per month (critical for identifying medication overuse headache - MOH risk)
- Preventive medications: Current and previously tried agents, doses, duration of trials, reasons for discontinuation
- Document number of preventive medication classes tried (important for refractory migraine classification) 4
Comorbidity Assessment
The template should screen for common migraine comorbidities that influence treatment selection 1:
- Psychiatric: Anxiety (78.1% in refractory patients), depression (71.5%) 4
- Pain conditions: Neck pain, back pain
- Cardiovascular: Hypertension (56% in refractory patients) 4
- Respiratory: Asthma (36.3% in refractory patients) 4
- Metabolic: Obesity (risk factor for chronification)
- Sleep disturbances 1
Special Populations
Women of childbearing potential:
- Menstrual relationship to attacks (pure menstrual migraine requires different management)
- Contraceptive use (combined hormonal contraceptives are absolutely contraindicated in migraine with aura due to stroke risk) 1
Pediatric considerations:
- Document if bed rest alone suffices for acute treatment 1
Follow-Up Template Components
Treatment Response Evaluation (2-3 months post-initiation, then every 6-12 months) 1
Key Outcome Measures:
- Attack frequency: Headache or migraine days per month
- Attack severity: Pain intensity (separate from functional consequence)
- Migraine-related disability: Functional impact assessment
- Acute medication use frequency: Monitor for MOH development
Headache Calendar Integration: The template should facilitate or link to electronic headache calendars capturing 1:
- Temporal occurrence of headaches
- Symptom severity on symptomatic days
- Acute medication use
- Menstruation timing (for women)
Treatment Adherence and Adverse Effects
- Medication adherence assessment
- Adverse events review
- Dosing optimization considerations 1
Data Reuse and Efficiency Features
The template should enable 5:
- Automated data entry where possible (device integration, vital signs)
- Elimination of redundancy (linkages for family history)
- Discrete data capture for quality metrics while maintaining clinical narrative utility
- Integration with patient-generated health data (patient portal access correlates with treatment engagement) 4
Clinical Decision Support Integration
The template should flag:
- Patients meeting criteria for preventive therapy consideration (≥2 days/month of impairment despite optimized acute therapy) 1
- Medication overuse patterns (frequent acute medication use)
- Need for specialist referral (diagnostically challenging, treatment-refractory, or complicated by comorbidities) 1
- Contraindications to specific treatments based on comorbidities 1
Common Pitfalls to Avoid
Do not conflate aggravating factors (worsen headache during attacks, like physical activity) with predisposing factors (increase susceptibility to attacks, like poor sleep) 1. The template should distinguish these clearly.
Avoid over-emphasis on trigger factors - true triggers are often self-evident and their role is frequently overemphasized 1.
Ensure the template captures whether patients are using acute medications early in attacks when headache is still mild, as this significantly impacts triptan effectiveness 1.