Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Frequent or worsening headaches / Headache chronicity (headaches occurring on >15 days/month)
May mention overuse of acute headache medications
History of Present Illness:
Describe the character, location, frequency, and severity of headaches.
Inquire about the onset and duration of increased headache frequency.
Assess the use of acute headache medications (medication type, frequency, duration of overuse).
Explore any precipitating factors for headaches (stress, lack of sleep, certain foods).
Past Medical History:
History of primary headaches (e.g., migraine, tension-type headache).
Previous treatments for headaches.
Medical conditions that may contribute to headaches (e.g., high blood pressure, sleep disorders).
Medications:
List all current medications, with particular emphasis on:
Acute headache medications (over-the-counter pain relievers, triptans, combination medications).
Preventative medications for headaches (if any).
Social History:
Inquire about stress levels, sleep habits, and lifestyle factors that may influence headaches.
Family History:
Family history of migraines or other headaches (may increase risk).
Physical Exam:
General examination: Focused on normal vital signs and absence of signs suggestive of secondary headaches (e.g., fever, meningismus).
Neurological examination: Assess for focal neurological deficits that could indicate a secondary cause.
Laboratory Tests (not routinely required, but may be indicated in specific situations):
Electrolytes to rule out electrolyte imbalance as a headache trigger.
Thyroid function tests if thyroid dysfunction is suspected.
Imaging Studies (not routinely required, but may be indicated):
Brain imaging (CT scan or MRI) may be considered if there is concern for a secondary cause of headaches (e.g., tumor, vascular malformation).
Assessment:
Medication overuse headache (MOH): Based on clinical presentation, history of medication overuse, and absence of concerning features on exam, diagnose MOH.
Headache type: Identify the underlying primary headache disorder (e.g., migraine, tension-type headache) contributing to MOH.
Plan:
Medication withdrawal: This is the cornerstone of MOH treatment. Discuss a tapering plan for overused acute headache medications with the patient. Consider offering alternative pain management strategies during withdrawal (e.g., behavioral therapies, non-steroidal anti-inflammatory drugs used judiciously).
Preventive headache medication: Discuss the importance of preventive medications to reduce headache frequency and severity once acute medication overuse is addressed. Select a preventive medication based on the underlying headache type and patient profile.
Non-pharmacologic therapy: Recommend non-pharmacological approaches for headache management, including:
Stress management techniques (relaxation training, biofeedback)
Improved sleep hygiene
Regular exercise
Follow-up: Schedule regular follow-up visits to monitor headache frequency, response to medication withdrawal and preventive treatment, and adjust treatment plan as needed.
Education:
Educate the patient about MOH, the importance of medication withdrawal, and the benefits of preventive treatment.
Provide resources for headache support groups or patient advocacy organizations.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Medication overuse headache is a common and treatable condition. Early diagnosis and appropriate management are crucial to break the cycle of medication overuse and improve headache control. It is recommended to consult with relevant medical resources and MOH management guidelines for comprehensive care planning.