What is the appropriate template for evaluating a patient presenting with headache?

Comprehensive Headache History Template

A thorough headache history is essential for accurate diagnosis, appropriate treatment, and improved patient outcomes. The following template provides a structured approach to documenting a patient presenting with headache 1.

Chief Complaint and Headache Characteristics

• Duration and onset: "The patient presents with a [X-day/week] history of headache that began [suddenly/gradually] on [date/time]."
• Location and radiation: "The headache is [unilateral/bilateral], primarily located in the [frontal/temporal/occipital/periorbital] region with radiation to [location if applicable]."
• Quality: "The patient describes the pain as [throbbing/pulsating/pressing/tightening/stabbing/sharp/dull]."
• Severity: "On a scale of 1-10, the patient rates the pain as [X/10] at its worst and [X/10] at its best."
• Timing pattern: "The headache occurs [continuously/intermittently], lasting approximately [duration] per episode with a frequency of [X times per day/week/month]."

Associated Symptoms

• Neurological symptoms: "The headache [is/is not] preceded by aura, which the patient describes as [visual disturbances/sensory changes/speech difficulties]."
• Autonomic features: "Associated symptoms include [nausea/vomiting/photophobia/phonophobia/lacrimation/nasal congestion/rhinorrhea/ptosis/miosis/eyelid edema]."
• Impact on function: "The headache [does/does not] worsen with routine physical activity and [has/has not] caused the patient to miss work/school or limit daily activities."

Aggravating and Alleviating Factors

• Triggers: "The patient identifies [specific foods/hormonal changes/stress/lack of sleep/weather changes/alcohol/caffeine/missed meals] as potential triggers."
• Relief measures: "The headache [improves/worsens] with [rest/sleep/darkness/quiet/position changes/medication]."
• Medication response: "The patient has tried [medications] with [complete/partial/no] relief."

Red Flags Assessment

• "The patient [denies/reports] concerning features such as [sudden onset/"worst headache of life"/headache awakening from sleep/headache with Valsalva/exertion/sexual activity/postural changes]."
• "There [is/is not] a history of recent head trauma, fever, neck stiffness, or neurological deficits."
• "The patient [does/does not] have risk factors such as age >50 years, cancer, immunosuppression, or pregnancy." 2

Past Medical History and Family History

• Previous headaches: "The patient [has/has not] experienced similar headaches in the past, with a [X-year] history of [migraine/tension/cluster] headaches."
• Family history: "There [is/is not] a family history of similar headaches or neurological disorders."
• Medical conditions: "Relevant medical history includes [hypertension/seizures/stroke/psychiatric disorders/sleep disorders]."

Medication and Substance Use

• Current medications: "The patient currently takes [medications] for headache management."
• Frequency of use: "Acute medications are used [X times per week/month], raising [no concern/concern] for medication overuse headache." 1
• Substance use: "The patient [uses/does not use] [caffeine/alcohol/tobacco/recreational drugs] which may [contribute to/not affect] the headache pattern."

Impact on Quality of Life

• "The headaches have resulted in [missed work/school days, inability to perform household chores, limited social activities, mood changes, sleep disturbances]."
• "The patient reports a headache diary showing [X] headache days per month, with [X] days of severe intensity requiring medication." 1

Physical Examination Findings

• Vital signs: "BP [X/X], HR [X], Temp [X]"
• Neurological examination: "Cranial nerves II-XII intact. No focal neurological deficits. No meningeal signs."
• Head and neck: "No tenderness over temporal arteries or sinuses. No cervical muscle tenderness or limited range of motion."

Assessment and Plan

• Primary diagnosis: "Based on the history and examination, the patient's presentation is most consistent with [migraine/tension-type/cluster/other primary headache disorder]."
• Secondary headache considerations: "Secondary causes [have been/need to be] ruled out based on [absence of red flags/neuroimaging/laboratory studies]."
• Treatment plan: "Management will include [acute medications/preventive therapy/lifestyle modifications/trigger avoidance]."
• Follow-up: "The patient will return in [timeframe] to assess treatment response and will maintain a headache diary in the interim."

This comprehensive template ensures thorough documentation of all relevant aspects of headache evaluation, facilitating accurate diagnosis and appropriate management 1, 3.