Patient: [Patient Name]
Date: [Date of Encounter]
I. History of Present Illness:
Onset date of current cluster headache episode:
Frequency of attacks per day:
Duration of individual attacks:
Location of pain: (e.g., unilateral periorbital, temporal)
Associated autonomic symptoms (e.g., ptosis, lacrimation, rhinorrhea, Horner’s syndrome):
Triggers identified (e.g., alcohol, lack of sleep):
Current medications for cluster headaches (prophylactic and abortive):
Response to current medications: (effective, partially effective, ineffective)
Impact on daily life (work, sleep, social activities):
II. Past Medical History:
Previous diagnoses of cluster headache: (yes/no)
If yes, date of first diagnosis:
Previous treatment history and response:
Any other relevant medical conditions:
III. Social History:
Smoking history: (current smoker, former smoker, never smoker)
Alcohol intake:
Caffeine intake:
Sleep habits:
IV. Physical Exam:
Vital signs: (BP, HR, RR, Temp)
Neurological exam: (grossly normal, focal deficits)
Cranial nerve exam: (focusing on III [oculomotor] for ptosis and Horner’s)
V. Assessment:
Active episodic cluster headache.
Consider including suspected ICHD-3 classification (e.g., episodic cluster headache, chronic cluster headache).
VI. Plan:
Treatment adjustments:
Prophylactic medications: (consider modifying regimen based on response)
Abortive medications: (consider adding/switching if not effective)
Non-pharmacological interventions: (e.g., oxygen therapy, sphenopalatine ganglion block)
Education: Patient education on cluster headaches, triggers, and treatment options.
Follow-up: Schedule a follow-up appointment to assess response to treatment and make further adjustments as needed.
VII. Notes:
Include any additional relevant information here, such as laboratory studies or imaging ordered (if applicable).
VIII. Resources:
Consider providing patient education materials on cluster headaches.