Date: [Date of encounter]
Patient: [Patient Name]
Chief Complaint:
Document the patient’s main concern related to the headache, such as tightness, pressure, or dull aching pain in the head and/or neck.
History of Present Illness:
Onset and duration of the current headache episode.
Frequency and typical duration of headaches.
Location, intensity, and quality of pain (dull ache, tightness, pressure).
Associated symptoms (e.g., scalp tenderness, neck pain, nausea, photophobia, phonophobia).
Precipitating factors (e.g., stress, lack of sleep, missed meals, dehydration).
Any recent changes in headache pattern or severity.
Self-management strategies used (e.g., over-the-counter pain relievers, relaxation techniques).
Past Medical History:
History of any other types of headaches (e.g., migraine).
Underlying medical conditions (e.g., anxiety, depression, high blood pressure).
Medications (including over-the-counter medications and herbal supplements).
Allergies (medications and other).
Social History:
Stress level and coping mechanisms.
Sleep habits (duration, quality).
Caffeine and alcohol intake.
Physical Exam:
Vital signs (blood pressure, heart rate).
General examination (assess for signs of fever, infection, or other medical conditions).
Neurological examination (gross motor and sensory function, cranial nerves).
Neck palpation (tenderness, trigger points).
Assessment:
Diagnosis of tension-type headache based on International Headache Society (ICHD-3) criteria.
Frequency (episodic or chronic).
Severity (mild, moderate, or severe) based on pain intensity and impact on daily activities.
Possible contributing factors (stress, muscle tension, sleep issues, medication overuse).
Plan:
Non-pharmacological Management:
Education on stress management and relaxation techniques (e.g., cognitive behavioral therapy, biofeedback).
Improve sleep hygiene (regular sleep schedule, relaxation techniques before bed).
Maintain good posture and ergonomics.
Regular exercise.
Pharmacological Management:
Discuss appropriate over-the-counter pain relievers for acute headaches (e.g., acetaminophen, ibuprofen).
Consider preventive medications for frequent or chronic headaches (discuss risks and benefits with patient).
Follow-up:
Schedule follow-up appointments to monitor response to treatment, adjust plan as needed, and address any concerns.
Consider referral to a headache specialist for complex cases.
Additional Notes:
Document any additional relevant information not covered above (e.g., patient education provided).
Disclaimer: This template is for informational purposes only and should be adapted to fit the specific needs of each patient. It is important to follow established guidelines for the diagnosis and management of tension-type headache