Proforma - Headache clinic
Unit No.
Date of GP Referral: _______________
Date seen: ________________________
Marital Status: ___________________________
Past Medical History (significant events in
chronological order)
Tick if none
______________________________________
Occupation: _____________________________
Current Drug Therapy (including
contraception & HRT)
Tick if none
______________________________________
______________________________________
______________________________________
______________________________________
Medication used in the past
______________________________________
______________________________________
Tick if none
Drug Name/Group
Reason for stopping
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
Social History
______________________________________
Smoking: No
Yes
Alcohol: No
_____ units per week
Negligible
Allergies
Tick if none
Drug Name
Type of Reaction
Drug Misuse: ________________________
Examination:
BP (Sitting): ____________BP (Standing): ____________
Heart Sounds
Normal
Abnormal
Pulse (Sitting): __________Pulse (Standing): __________
Bruits/Murmurs
No
Yes
Peripheral Pulses
Normal
Reduced
Absent
Corrected Visual Acuity: R _______________ L _____________________
Fundi
Normal
SVP(R)
SVP(L)
Abnormal __________
Temporal Arteries
Pulsatile and non tender
Abnormal _________________________
Cranial Nerves
Normal
Abnormal _________________________
Arms (Tone/Power) Sensation
Normal
Abnormal _________________________
Legs (Tone/Power)Sensation
Normal
Abnormal _________________________
Co-ordination
Normal
Abnormal _________________________
Reflexes
Normal
Abnormal _________________________
Other comments: ________________________________________________________________________
1
Tests/Investigations
Done before
(tick if Yes)
Comment on
Result
Date
requested
Date Done
Done in Clinic
Comment on
Result
FBC
ESR
U & E, LFT
LFT, (Ca, Po4)
Glu
TFT
B12/Folate
Autoantibodies
Summary of
Result
GP/patient
informed of result
CT
MRI
Lumbar Puncture
EEG
Other 1:
Other 2:
Other 3:
Outcome of Clinic Visit
1. Diagnosis
Migraine without aura
Migraine with aura
Tension-type headache
Chronic daily headache
Cluster headache
Post-traumatic headache
Benign intracranial hypertension
Drug induced
Cervical spondylosis
No diagnosis made
Structural Lesion (please specify): _____________
Other: ___________________________________
2.
Discharged back to GP
Admitted
Continuing to attend as out patient
Awaiting further investigation as out patient
Other: _______________________
Information sheets given to patients:
What is Migraine?
Common Types of Headache
Headache on the Internet
Patient Information leaflets:
Rizatriptan (Maxalt) tablets
Rizatriptan (Maxalt) Melt
Zolmitriptan (Zomig)
4. Treatment Recommended
Propranolol (Inderal LA)
Prophylaxis
Pizotifen (Sanomigran)
Propranolol
80mg LA
Other: _______________
Sanomigran
0.5mg
1.0mg
1.5mg
Other: ______________
Cyproheptadine
4mg increased weekly to tid
Other: ____________________________
Amitriptyline
10 mg
25mg
Other: ____________________________
Acute
Ibuprofen
200mg
400mg
Other: ____________________________
Domperidone
10mg
Other: __________________________________________
Metoclopramide
10mg
Prochlorperazide
5mg
Buccastem
3mg
Sumatriptan
Tablets 50mg
Tablets 100mg
Nasal Spray 20mg
Injection 12mg
Naratriptan
2.5mg
Zolmitriptan
2.5mg
5mg
Rizatriptan
10mg
Other 1
Other 2
5. Side effect discussed
Yes
3.
Pregnancy/Contraception issues
2