New Patient - Beat Headache

Name

DOB

Age

Gender

Ethnicity

Birth History

Parity of Mother

Duration of Gestation(weeks)

Birth Weight

Mode of Delivery

Consanguinity

Famili Income (Monthly)

Perinatal History

PBU Stay

If Yes, Days

Select

Other

Family History

Relation

Age

Occupation

Select

Describe

Confirm “headache” and visiting clinical characteristics.

ExcludeToothacheEar painThroat PainNeck pain

Headache Confirmed

HISTORY OF THE HEADACHE

Age

Duration

Location constant / variable

Frontal

Temporal

OccipitalAlloverBand likeVertex

PAINConstant pressure, tightening (like a band)Throbbing or pulsing (like a heart beat)Sharp or stabbingThunder clapping

HOW MANY TIMES

DURATION: How long did the pain last?1-2 Hour2-4 HourMore than 04 HoursAll day

Intensity of the headache (0-No Hurt – 10 Hurts Worst

What makes the pain feel better? Others (specify)

Aggravating FactorsActivityWalkingClimbing StairsReading

Past Medical History

Past Surgical History

Drug History (if any)

History of allergiesFoodDrugPlaster

History of allergies(Please Specify)

Identification of Life Threatening Headache (Red Flags)

SYSTEMIC SIGNS/SYMPTOMSFever, acute symptomsVomitingWeight lossComorbidities

Verifying – Secondary headache status (structural, function, metabolic of other)

Parental Evaluation

Intelligence

Notes

Behavior

Notes

Attention

Notes

Memory

Notes

Reading ability

Notes

Writing ability

Notes

Mathematical ability

Notes

School Evaluation

Intelligence

Notes

Behavior

Notes

Attention

Notes

Memory

Notes

Reading ability

Notes

Writing ability

Notes

Mathematical ability

Notes

Professional Evaluation

Intelligence

Notes

Behavior

Notes

Attention

Notes

Memory

Notes

Reading ability

Notes

Writing ability

Notes

Mathematical ability

Notes

Diagnosing Primary headaches – as per International Headache Society (IHS) Standards.

Section 1 : ICHD-3 diagnostic criteria for MIGRAINE without AURA

Total number of attacks five or more

Headache attacks lasting 4-72 hr

Headache has at least two of the following four characteristics:

unilateral locationpulsating qualitymoderate or severe pain intensityaggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)

During headache at least one of the following

nausea and/or vomitingphotophobia and phonophobia

Diagnosis :ConfirmedIncompleteUnlikely

Section 2: ICHD-3 diagnostic criteria for MIGRAINE WITH AURA

Total number of attacks two or more

One or more fully reversible aura (visual/ sensory/ speech and language/ motor/ brainstem/ retinal) symptoms

At least three of the following six characteristics

Checkboxat least one aura symptom spreads gradually over ≥5 minutestwo or more aura symptoms occur in successioneach individual aura symptom lasts 5-60 minutesat least one aura symptom is unilateralat least one aura symptom is positivethe aura is accompanied, or followed within 60 minutes, by headache

Patient’ s headache cannot be attributed to another disorder

Diagnosis :ConfirmedIncompleteUnlikely

Section 3: ICHD-3 diagnostic criteria for TENSION TYPE HEADACHE

At least 10 episodes of headache occurring on <1 day/month on average (<12 days/year)

Lasting from 30 minutes to 7 days

At least two of the following four characteristics:

bilateral locationpressing or tightening (non-pulsating) qualitymild or moderate intensitynot aggravated by routine physical activity such as walking or climbing stairs

Both of the following

no nausea or vomitingno more than one of photophobia or phonophobia

Patient’ s headache cannot be attributed to another disorder

Diagnosis :ConfirmedIncompleteUnlikely