Sample Headache History

Headache history: Tuesday, June 17, 2003 10:57:29 PM

Main headache description: The patient is describing a severe throbbing and intense pain in the right forehead, right temple and back of the head. Sidedness of the pain is not specific. These are most likely to occur in the spring and in the fall and usually in no set pattern on Saturdays and on Sundays. The headache attacks are occurring at an undefined frequency while the frequency is worsening in recent months and the severity remains stable with no worsening or improvement. The headaches last from 4-72 hours and it is unclear if there are periods without headache. There is no cyclical pattern. There have been more than 10 attacks of this type.

Well before the headache begins, the patient reports yawning while the aura can include flashing lights and zig zags of light. Denies premonitory tinnitus, decreased hearing during these episodes, ataxia, decreased level of consciousness, ringing in the ears, hearing loss, clumsiness or staggering, torpor, tingling scalp, tightening of neck, weakness, double vision, visual loss, confusion, slurred speech, loss of speech, droopy eyelid, facial numbness, facial drooping, loss of feeling or tingling and spinning sensations. Flashing lights last less than 30 minutes. Zig zags last less than 30 minutes. The headaches are accompanied by nausea, vomiting, light sensitivity, neck pain and pallor. Denies accompanying dysosmia, nasal congestion, droopy eyelid, lacrimation, scalp tenderness, abdominal cramping, diarrhea, constipation, hunger, thirst, tinnitis, lightheadedness, vertigo, burning pain in scalp, visual blurring, restlessness, need to pace the floor, confusion, depression, anxiety, excessive fatigue, red eye, clear nasal drainage, facial sweating or change in pupil size.

The patient is of childbearing age, no birth control in use. During pregnancy there was improvement in second trimester. Hormonal factors worsening headaches include worsening before periods.

Modifying factors: Life events which may have initiated the headaches include puberty. Denied any specific trauma related abnormalities. Headaches can be triggered by oversleeping, stress, bright lights and odors. Exacerbating factors include head movement and lying down. Headaches can be relieved by medication, lying in a dark room and sleep.

Medication rescue attempts have included over the counter analgesics, prescription analgesics and triptans. Over the counter analgesics are being used 3 or more times per week. Prescription analgesics are being used about twice per week or less. No triptans have been tried. Triptans are being used about twice per week or less. Successful attempts with headache preventative medications have included Norpramine. Has never tried anti-inflammatories, ergotamines, Maxalt tabs, Maxalt MLT, Zomig MLT, Zomig nasal spray, Axert tabs, Relpax tabs, Amerge, Frova, Imitrex nasal spray, antiseizure meds, blood pressure meds, Sinequan, Prozac, Lexapro, Effexor, Parnate, Celexa, Wellbutrin or Paxil to control headaches. Elavil and Nardil were not tolerated. Unsuccessful treatments include biofeedback and herbal preparations. Did not tolerate acupuncture or manipulation of the neck. Reports previous response to physical therapy. Rebound medication usage patterns are suggested by the current use of OTC meds.

Previous attempts: Previously treated by psychiatrist, family practitioner and urgent care. Has never been to a neurologist or an emergency room. Past testing includes blood tests and CT scan of the head. The patient has been given the diagnoses of tension headache and sinus headache.

Impact on life: includes missing work, missing social functions and causing frustration.

Headache oriented positive ROS: anxiety. Cervical pain is present only on headache days. Denies clenching or grinding teeth, painful jaws when awakening in the morning, sweating, palpitations, seizures, poorly controlled blood pressure or discolored nasal drainage.

Family members with known headache complaints include mother and sister. Migraine-like symptoms in childhood include motion sickness with carnival rides. Support system includes spouse and clergy.