Neurology — Headache Evaluation Template

Visit Information

Date: [Date]
Visit type: New / Follow-up
Last visit: [Date]
Current headache status: Active / Resolved / Chronic daily

Chief Complaint

[Primary headache concern]
Current headache: Yes / No — Duration: [X] hours/days
Headache-free days per month: [X]/30

Red Flag Assessment (SNOOP)

[ ] S - Systemic symptoms (fever, weight loss, cancer, HIV)
[ ] N - Neurological symptoms or signs
[ ] O - Onset sudden (thunderclap)
[ ] O - Older age at onset (>50 years)
[ ] P - Pattern change (progressive, new type)
[ ] P - Positional (worse lying down)
[ ] P - Papilledema
[ ] P - Precipitated by Valsalva
[ ] P - Pregnancy/postpartum
Red flags present: None / [List] — Urgent workup needed: Yes / No

Headache History

Current Headache Type(s)

Primary headache type: Migraine / Tension-type / Cluster / TAC / Other

Headache 1 (Primary):

Frequency: [X] days per month
Duration untreated: [X] hours
Location: Unilateral / Bilateral / [Specific location]
Quality: Throbbing / Pressure / Stabbing / Burning
Severity: [X]/10 average, [X]/10 worst
Timing: Any time / Morning / Evening / Nocturnal / Menstrual
Associated features:
[ ] Nausea
[ ] Vomiting
[ ] Photophobia
[ ] Phonophobia
[ ] Osmophobia
[ ] Cutaneous allodynia
[ ] Cranial autonomic symptoms: [Lacrimation, rhinorrhea, ptosis, miosis]
Aura: None / [X]% of attacks
Type: Visual / Sensory / Motor / Speech / Brainstem / Retinal
Duration: [X] minutes
Timing: Before headache / With headache / Without headache

Headache 2 (if different type):

[Repeat format if patient has multiple headache types]

Triggers

Identified triggers:
[ ] Stress [ ] Sleep changes [ ] Weather/barometric pressure
[ ] Hormonal (menses, ovulation) [ ] Alcohol [ ] Caffeine
[ ] Foods: [Specific]
[ ] Skipping meals [ ] Dehydration [ ] Bright lights
[ ] Strong odors [ ] Physical exertion [ ] Sexual activity
[ ] Other: [Specify]
Premonitory symptoms: None / [Fatigue, mood changes, neck stiffness, yawning, food cravings]
Postdrome: None / [Fatigue, cognitive difficulties, mood changes]

Headache Pattern

Age of onset: [X] years
Initial pattern: Episodic / Chronic from onset
Current pattern: Episodic (<15 days/month) / Chronic (≥15 days/month)
Transformation date: [If episodic → chronic]
Headache-free periods: Yes / No

Disability Assessment

MIDAS Score: [X] — Grade [I/II/III/IV]

• Days missed work/school: [X]
• Days reduced productivity at work: [X]
• Days missed household activities: [X]
• Days reduced household productivity: [X]
• Days missed family/social/leisure: [X]

HIT-6 Score: [X] — [Little/Some/Substantial/Severe] impact
Functional impact:

• Work: [Full capacity, reduced, disability]
• Social: [Active, limited, isolated]
• Sleep: [Normal, disrupted]
• Mood: [Normal, depression, anxiety]

Current Treatment

Acute Medications

Medication	Dose	Frequency/month	Efficacy	Side effects
[Name]	[Dose]	[X days]	[Good/Fair/Poor]	[None/List]

Acute medication use days/month: [X]
Medication overuse: No / Yes — Type: [Triptan, analgesic, combination, opioid]

• Criteria: Triptans ≥10 days, simple analgesics ≥15 days, combination ≥10 days

Time to efficacy: [X] hours
Pain-free at 2 hours: Yes / No — [%]
Sustained relief (24 hours): Yes / No — [%]

Preventive Medications

Current preventive(s):

Medication	Dose	Duration	Response	Side effects
[Name]	[Dose]	[X weeks/months]	[X% reduction]	[None/List]

Prior preventives tried:

Medication	Max dose	Duration	Reason stopped
[Name]	[Dose]	[Duration]	[Ineffective/side effects/other]

Non-Pharmacological Treatments

[ ] Behavioral therapy/biofeedback — Response: [Good/Fair/Poor]
[ ] Physical therapy — Response: [Good/Fair/Poor]
[ ] Acupuncture — Response: [Good/Fair/Poor]
[ ] Nerve blocks — Type: [GON, trigger point] — Response: [Good/Fair/Poor]
[ ] Neuromodulation — Device: [sTMS, eNS, VNS] — Response: [Good/Fair/Poor]
[ ] Botox — Response: [Good/Fair/Poor]

Comorbidities

Psychiatric:

• Depression: No / Yes — PHQ-9: [X]
• Anxiety: No / Yes — GAD-7: [X]
• PTSD: No / Yes
• Bipolar: No / Yes

Sleep:

• Insomnia: No / Yes
• Sleep apnea: No / Yes — On CPAP: Yes / No
• Poor sleep hygiene: No / Yes

Medical:

• Hypertension: No / Yes
• Obesity: No / Yes — BMI: [X]
• Chronic pain syndromes: No / Yes — [Type]
• Fibromyalgia: No / Yes

Physical Examination

Vital Signs

BP: [X/X]
HR: [X]
Weight: [X] — BMI: [X]

General

Appearance: Well / [Distressed, photophobic]
Pain behaviors: None / [Guarding, grimacing]

Head and Neck

Scalp tenderness: None / [Location]
Temporal arteries: Normal / Tender / Thickened / Reduced pulse
Trigger points: None / [Location — trapezius, SCM, occipital]
Cervical ROM: Full / Limited [direction]
TMJ: Normal / Tenderness / Click / Limited opening

Neurological

Mental status: Alert and oriented
Cranial nerves: Intact / [Abnormality]
Fundoscopy: Normal / [Papilledema, venous pulsations]
Visual fields: Full / [Deficit]
Pupils: PERRL / [Anisocoria, Horner's]
Facial sensation/strength: Intact / [Asymmetry]
Motor: [5/5] throughout / [Weakness]
Sensory: Intact / [Deficit]
Reflexes: Symmetric / [Asymmetry]
Coordination: Normal / [Dysmetria]
Gait: Normal / [Ataxia]

Allodynia Assessment (if applicable)

Thermal: Absent / Present — Location: [X]
Mechanical static: Absent / Present — Location: [X]
Mechanical dynamic: Absent / Present — Location: [X]

Diagnostic Studies

Imaging:

• MRI brain: [Date, findings]
• MRA: [Date, findings]
• CT head: [Date, findings]

Laboratory (if indicated):

• ESR/CRP: [If GCA concern]
• Thyroid: [If indicated]
• Other: [Specific]

Assessment

Diagnosis (ICHD-3 Classification)

1) [Primary diagnosis] — [Episodic/Chronic]

• Frequency: [X] days/month
• Disability: MIDAS Grade [X]

2) [Secondary diagnoses if applicable]

• Medication overuse headache: Yes / No
• [Other]

Response to Current Treatment

Acute: Adequate / Inadequate — [%] response
Preventive: Adequate / Inadequate — [%] reduction
Overall control: Well-controlled / Partially controlled / Poorly controlled

Plan

Acute Treatment

Continue: [Current effective acute medications]
Change/Add:

• [Medication, dose, max per week]
• Rescue: [Medication for refractory attacks]

Instructions:

• Treat early when pain is mild
• Limit acute medications to [X] days per week
• [Other specific instructions]

Preventive Treatment

Continue: [Current preventive if working]
Adjust: [Dose change]
Add/Change to:

• [New preventive, starting dose, titration schedule, target dose]
• Rationale: [Why this choice — comorbidities, side effect profile, efficacy]

Timeline: Assess efficacy at [X] weeks
Goal: [X]% reduction in headache days

CGRP-Targeted Therapy (if indicated)

[ ] Anti-CGRP mAb: [Erenumab, fremanezumab, galcanezumab, eptinezumab]
[ ] Gepant (preventive): [Atogepant, rimegepant]
Indication: [Failed X conventional preventives]
Monitoring: [Constipation, injection site reactions]

Botox (if indicated)

Indication: Chronic migraine (≥15 days/month, ≥8 migraine days)
Protocol: 155-195 units, 31-39 injection sites
Frequency: Every 12 weeks
Prior authorization: [Status]

Non-Pharmacological

[ ] Headache diary — Track: [Frequency, severity, triggers, medications]
[ ] Lifestyle modifications:

• Sleep hygiene: Regular schedule, [X] hours
• Hydration: [X] oz daily
• Exercise: [X] minutes, [X] times/week
• Trigger avoidance: [Specific]
• Stress management: [Techniques]

[ ] Behavioral therapy: [Biofeedback, CBT for headache]
[ ] Physical therapy: [Neck, posture, trigger points]
[ ] Nerve block: [GON, trigger point] — Schedule: [X]

Medication Overuse Management (if applicable)

[ ] Education on MOH provided
[ ] Taper/discontinue: [Medication]
[ ] Bridge therapy: [Steroid taper, nerve block, etc.]
[ ] Preventive optimization during withdrawal

Mental Health

[ ] Depression/anxiety screening: [Results]
[ ] Mental health referral: [If indicated]
[ ] [Treatment if applicable]

Follow-up

Return: [X] weeks/months

• Purpose: [Assess preventive efficacy, adjust treatment]
• Bring: Headache diary
• Sooner if: [New neurological symptoms, significant worsening, red flags]

Patient Education

• Headache pathophysiology and treatment rationale
• Medication instructions and side effects
• Importance of headache diary
• Medication overuse prevention
• Trigger management
• When to seek urgent care