Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Migraine headache (new or follow-up)
(Specify) Throbbing or pulsating headache, usually unilateral, lasting 4-72 hours, associated with nausea, vomiting, photophobia (light sensitivity), and phonophobia (sound sensitivity) (may not have all symptoms)
History of Present Illness:
Onset, duration, and severity of current migraine attack.
Frequency of migraine attacks (e.g., episodic, chronic).
Characteristics of headache (location, quality, severity).
Associated symptoms (nausea, vomiting, photophobia, phonophobia, aura).
Precipitating factors (e.g., stress, lack of sleep, hormonal changes, certain foods).
Medications used for this attack (prescription or over-the-counter).
Past Medical History:
Previous diagnoses of migraine (with or without aura).
Other medical conditions (e.g., high blood pressure, depression).
Medications (including potential triggers like birth control pills).
Family History:
Family history of migraine (first-degree relatives have a higher risk).
Social History:
Occupation and stress levels (stress can be a trigger).
Sleep habits (irregular sleep can worsen migraines).
Diet (identify potential food triggers).
Substance use (caffeine withdrawal, alcohol use can trigger migraines).
Physical Exam:
Vital signs (normal in most cases unless complicated migraine).
Neurological exam: Assess for focal neurological deficits (suggesting complicated migraine or other neurological conditions).
Assessment:
Migraine: Based on clinical presentation (headache characteristics, associated symptoms) and migraine history.
Migraine type: Differentiate between migraine with aura and migraine without aura based on the presence or absence of aura (visual disturbances or other sensory symptoms preceding the headache).
Migraine severity: Evaluate the severity of the attack based on headache intensity, duration, and functional limitations.
Differential diagnoses: Consider and rule out other causes of headache (e.g., medication overuse headache, cluster headache, tension-type headache, meningitis).
Plan:
Acute treatment: Medications to address the current migraine attack may include:
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Triptans (vasoconstrictors specifically for migraines)
Antiemetics (for nausea and vomiting)
Rest in a dark, quiet room
Preventive treatment: If migraines are frequent or severe, consider preventive medications to reduce their frequency and severity. Options include:
Beta-blockers
Antidepressants
Anticonvulsants
Lifestyle modifications: Recommend lifestyle changes that may help prevent migraines, such as:
Maintaining a regular sleep schedule
Managing stress
Identifying and avoiding triggers
Eating a healthy diet
Staying hydrated
Follow-up: Schedule a follow-up visit to assess response to treatment and discuss preventive strategies.
Education:
Educate the patient about migraine, types, triggers, and treatment options.
Provide information on maintaining a headache diary to track symptoms and identify triggers.
Discuss the importance of avoiding medication overuse headaches.
Advise on relaxation techniques and stress management strategies.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Migraines can be a debilitating condition. Early diagnosis and appropriate treatment are crucial to improve quality of life and prevent complications.