COLUMBIA UNIVERSITY HEADACHE CENTER: NEW PATIENT QUESTIONNAIRE
|
|
|
- Silas Park
- 5 years ago
- Views:
Transcription
1 COLUMBIA UNIVERSITY HEADACHE CENTER: NEW PATIENT QUESTIONNAIRE HEADACHE CHARACTERISTICS Frequency and Severity 1. At what AGE did you get your first headache, of ANY kind? 2. At what AGE did your headaches become problematic? 3. On AVERAGE, how many DAYS per MONTH do you get headaches, of ANY KIND? 4. On AVERAGE, how long do your typical headaches last? (MINUTES, HOURS, DAYS) 5. On a scale of zero to ten, how would you rate your WORST pain? (please circle your answer) no pain mild moderate severe 6. On a scale of zero to ten, how would you rate your AVERAGE pain? (please circle your answer) no pain mild moderate severe 7. How many DAYS per MONTH do you get your WORST headaches? 8. How long do your WORST headaches last? (MINUTES, HOURS, DAYS) Location(s) Left Right Front Back 1. Please indicate the regions affected: 2. Is one side affected more than another?!left side only!yes, % more on the left side!right side only!yes, % more on the right side!, both sides equally affected!, alternates equally 3. What region(s) is/are affected?! Front of the head! Back of the head! Side of the head! Top of the head! Around the Eyes! Behind the Eyes! Shoulder! Neck! Ear! se! Jaw! Other Quality/Description of Pain How would you describe your pain?! Throbbing! Tearing! Dull! Aching! Stabbing! Sharp! Sudden! Squeezing! Pounding! Pressure! Gradual! Tightening! Pulsating! Burning! Constant! Other Associated Features When you have head pain, do you have any of the following?! Sensitivity to light! Sensitivity to sound! Sensitivity to smell! Sensitivity to movement! Nausea! Vomiting Room spinning Self spinning Lightheadedness Blurry vision Difficulty concentrating Tearing of the eye ( right / left / both ) Redness of the eye ( right / left / both ) Drooping of the eye ( right / left / both ) Nasal congestion ( right / left / both ) Runny nose ( right / left / both ) Facial flushing ( right / left / both ) Ear fullness ( right / left / both )
2 Have you experienced any of the following? Head or neck trauma? Loss of consciousness? Infection/illness BEFORE the onset of your headache? Toxic exposure BEFORE the onset of your headache? Snoring or breathing pauses? Jaw clicking, difficulty opening mouth, tooth grinding? Use of tetracycline antibiotics, retinoic acid/vitamin A creams BEFORE the onset of your headache? Have you been diagnosed with any of the following? Anxiety Anorexia Psychosis Bipolar Disorder Bulimia Obsessive Compulsive Disorder Depression Posttraumatic Stress Other psychiatric disorder DIAGNOSTIC STUDIES Please provide dates and details of any studies, tests, or images that have been performed: (Attach copy of test results if possible) Study Date Findings! BRAIN MRI! NECK (Cervical) MRI! MRA/MRV! Head CT! Lumbar puncture! Sleep Study! EEG Other
3 Medication Generic Name (Brand Name) PAST PREVENTIVE MEDICATIONS What was the highest dose (mg)? How many times per day? When/how long was this used? Did this change the intensity, duration or frequency of the headache? (If so, how?) Were there any side effects? (If so, what were they?) Amitriptyline (Elavil) rtriptyline (Pamelor) Doxepin (Sinequan) Imipramine (Tofranil) Cyproheptadine (Periactin) Venlafaxine (Effexor) Duloxetine (Cymbalta) Escitalopram (Lexapro) Topiramate (Topamax) Zonisamide (Zonegran) Valproate (Depakote) Gabapentin (Neurontin) Lamotrigine (Lamictal) Carbamazepine (Tegretol) Oxcarbazepine (Trileptal) Acetazolamide (Diamox) Propranolol (Inderal) Nadolol (Corgard) Atenolol (Tenormin) Metoprolol (Toprol) Candesartan (Atacand) Flunarizine (Sibelium) Verapamil (Calan, Veralan) Indomethacin (Indocin) Lithium (Eskalith, Lithobid)) Methysergide (Sansert) Vitamin B2 (Riboflavin) Magnesium Butterbur (Petadolex) Feverfew Melatonin
4 PAST ACUTE MEDICATIONS Medication Dose (mg) Route of administration (oral, nasal, injection) Did this change the intensity or duration of the headache? (If so, how?) Were there any side effects? (If so, what were they?) Sumatriptan (Imitrex) Treximet Rizatriptan (Maxalt) Zolmitriptan (Zomig) Naratriptan (Amerge) Eletriptan (Relpax) Almotriptan (Axert) Frovatriptan (Frova) Ergotamine tablets (Cafergot, Ergomar, Migergot, Migracet, Wigraine) Ergotamine suppository (Cafergot) Dihydroergotamine nasal spray (Migranal) Promethazine (Phenergan) Chlorpromazine (Thorazine) Prochlorperazine (Compazine) Metoclopramide (Reglan) Naproxen (Naprosyn, Aleve) Ibuprofen (Advil, Motrin) Acetaminophen/Aspirin/Caffeine (Excedrin) Nabumetone (Relafen) Flurbiprofen (Ansaid) Mefenamic Acid (Ponstel) Ketorolac (Toradol) Diclofenac (Cambia, Voltaren) Steroids (e.g., Medrol, prednisone) Muscle relaxants (e.g., tizanidine, methocarbamol) Butalbital-containing compounds (Fioricet, Fiorinal) IN THE PAST, WHAT OTHER MEDICATIONS FOR HEADACHE HAVE YOU USED? (Attach additional sheets if needed) How many Did this change the intensity, Medication What was the When/how long Were there any side effects? (If so, what times per duration or frequency of the highest dose (mg)? was this used? were they?) day? headache? (If so, how?)
5 INTRAVENOUS THERAPIES, HOSPITALIZATIONS, and PROCEDURES FOR HEADACHE Treatment Date Description of Treatment and Effect Intravenous DHE (dihydroergotamine) Intravenous valproic acid (Depakote) Intravenous lidocaine Greater occipital nerve block Botox Injections Implanted stimulator device Surgical intervention Other: ADJUNCTIVE THERAPIES Type of Treatment Date Effect Cefaly (supraorbital nerve stimulator) Transcranial Magnetic Stimulation (TMS) Oxygen therapy Acupuncture Biofeedback TENS therapy Chiropractic Manipulation Massage Therapy Physiotherapy Homeopathy Other:
6 MIDAS (Migraine Disability Assessment) About MIDAS: The MIDAS (migraine assessment) questionnaire is a tool to help you measure the impact your headaches have on your life over the last 3 months. The best way to this is by counting the numbers of of your life which are affected by Headaches. You can do this for yourself as follows: INSTRUCTIONS: Please complete Questions about ALL your headaches you have had over the last 3 months. Write your answer in the box next to each question. If a single headache affects more than one area of your life (e.g., work and family life) it is counted more than once. Mark question as zero if you did not do the activity in the last three months. For questions 1 and 2, work or school means paid work or education if you are a student at school or college. For Questions 3 and 4, household work means activities such as housework, home repairs and maintenance, shopping as well as caring for children and relatives. 1. On how many in the last 3 months did you miss work or school because of your headaches? 2. How many in the last 3 months was your productivity at work or school reduced by half or more because of your headaches? (Do not include you counted in question 1 where you missed work or school) 3. On how many in the last 3 months did you not do household work because of your headaches? 4. How many in the last 3 months was your productivity in household work reduced by half or more because of your headaches? (Do not include you counted in question 3 where you did not do household work) 5. On how many in the last 3 months did you miss family, social or leisure activities because of your headaches? To score, add points for answers in each column Total: MIDAS Score MIDAS Grade 0 5 I 6 10 II Definition Minimal or infrequent Mild or infrequent Recommendations MIDAS Grade I usually indicates low medical need. Simple, over-the-counter analgesics may be effective in the acute treatment of these patients. However, the impact of even a few lost on the lifestyle of these patients should be assessed. Also, some patients with a MIDAS Grade I, such as those with infrequent, but severe migraine, may benefit from first-line treatment with specific migraine therapies (e.g. triptans). MIDAS Grade I patients who have failed to achieve effective relief with simple analgesics should also be considered for triptan therapy. MIDAS Grade II usually indicates moderate medical need. The patients may require an acute prescription medication. Some MIDAS Grade II patients may also qualify for first-line triptan medication if their headaches are severe. For example, a score of 10 could mean that a patient is missing ten of school or paid work, so the headaches could be causing severe disruption in their lives. MIDAS Grade II patients should also qualify for first-line triptan medication if they have failed on simple analgesics III 21 IV Moderate Severe MIDAS Grade III/IV indicates a high medical need. These patients are experiencing significant and their migraine attacks are having a severe impact on their lives. Specific acute therapy, such as a triptan, is usually the most appropriate therapy for these patients, providing they are suitable recipients. Prophylactic treatment should also be considered. Please note that a very high MIDAS score could also indicate a high frequency of nonmigraine headache, and these patients should be managed accordingly. Patient s Signature Reviewed with the patient on Physician s Signature
~ ColumbiaDoctors Adult New Patient Intake Form Patient Information
~ ColumbiaDoctors Adult New Patient Intake Form Patient Information Last Name: First Name: DOB: Gender: Home Phone: Mobile Phone: ---------- Preferred Phone: Home or Mobile (circle one) Email: -----------
~ ColumbiaDoctors Adult New Patient Intake Form Patient Information
~ ColumbiaDoctors Adult New Patient Intake Form Patient Information Last Name: First Name: DOB: Gender: Home Phone: Mobile Phone: ---------- Preferred Phone: Home or Mobile (circle one) Email: -----------
Headache Questionnaire
Date: All Headache Patients We would appreciate your cooperation in filling out this form. In our evaluation of headache, your history is typically our most valuable tool for diagnosis and subsequent treatment.
Come prepared: What you can expect:
Welcome! Thank you for choosing the Headache Clinic at University of Colorado Hospital for your health care needs. Targeting the best outcomes for patients, our providers bring together top expertise and
1. On how many days in the last 3 months did you miss work or school because of your headaches?
The Migraine Disability Assessment Test The MIDAS (Migraine Disability Assessment) questionnaire was put together to help you measure the impact your headaches have on your life. The information on this
Neuroscience Institute Headache Center Intake Form. Please list ALL medications you are currently taking, including over-the-counter
Neuroscience Institute Headache Center Intake Form Please list ALL medications you are currently taking, including over-the-counter medications and supplements: Medication Allergies: Past Medical History:
MIGRAINE UPDATE. Objectives & Disclosures. Learn techniques used to diagnose headaches. Become familiar with medications used for headache treatment.
MIGRAINE UPDATE Karen L. Bremer, MD November 16, 2018 Objectives & Disclosures Learn techniques used to diagnose headaches. Become familiar with medications used for headache treatment. Disclosure: I am
General Patient Information Dr. David A. Branch, M.D.
General Patient Information Dr. David A. Branch, M.D. **Please Print** Patient Name: Date of Birth: Social Security # Email Address: Patient Address: _ City: State: Zip Code: Phone : Marital Status: S
Chantal O Brien, MD Jeff Reynek, NP Jessica Scharein, DNP
Welcome! Thank you for choosing the Headache Clinic at University of Colorado Hospital for your health care needs. Targeting the best outcomes for patients, our providers bring together top expertise and
Short Clinical Guidelines: Headache, Key Points for Diagnosis and Treatment
Clinical Highlights 1. Headache is diagnosed by history and physical examination with limited need for imaging or laboratory tests. 2. Warning signs of possible disorder other than primary headache are:
Current Complaint Please briefly describe the reason for your visit to our office today:
MEDICAL HISTORY Please complete the following information: Patient name: D.O.B. Date: *The following information is very important to us in taking care of your health. Please take the time to fill out
Thank you, again, for allowing us to participate in your health care. We look forward to working with you!
Welcome! Thank you for choosing the Headache Clinic at University of Colorado Hospital for your health care needs. To obtain the best outcomes for patients, the providers at the UCHealth Headache Clinic
OH, MY ACHING HEAD! I HAVE NO DISCLOSURES OR CONFLICTS OF INTERESTS TO DECLARE MANAGING HEADACHE IN THE OUTPATIENT SETTING SECONDARY HEADACHES
1 JUSTIN A. OSSMAN, MD CHATTANOOGA FAMILY MEDICINE UPDATE OH, MY ACHING HEAD! MANAGING HEADACHE IN THE OUTPATIENT SETTING 2 I HAVE NO DISCLOSURES OR CONFLICTS OF INTERESTS TO DECLARE OBJECTIVES International
Faculty Disclosure. Karen L. Bremer, MD. Dr. Bremer has listed no financial interest/arrangement that would be considered a conflict of interest.
Faculty Disclosure Karen L. Bremer, MD Dr. Bremer has listed no financial interest/arrangement that would be considered a conflict of interest. HEADACHE UPDATE Karen L. Bremer, MD November 10, 2017 karen.bremer@creighton.edu
Department of Neurology Headache Questionnaire
Department of Neurology Headache Questionnaire first Name: last Name: Date of birth: primary care provider & clinic: previous neurologist: At what age did you have your first headache: What year did your
Head Pain Intake Form
Head Pain Intake Form NEUROLOGY LLC Your evaluation will take one hour to complete and in order to best utilize the time, please take the time to complete this questionnaire prior to your appointment.
Headache. Headache Case. Migraine Headache. Eric Kraus, MD. Types» Without aura (common)» With aura (classic)
Headache Eric Kraus, MD Headache Case This 23 year-old female has headaches behind the right eye that cause her to lay down in a quiet room. They have a throbbing quality and she may vomit. Migraine Headache
PATIENT REGISTRATION
Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
Medication For Migraine Chart: Table 1: Acute Treatment when the attack begins
Medication For Migraine Chart: Table 1: Acute Treatment when the attack begins Page a Analgesics (painkillers) Non-steroidal antiinflammatory drugs (NSAIDs) Prescription required Brand Name Formulation
Understanding Migraines
Understanding Migraines Migraine is a severe headache syndrome that recurs. Migraine headaches are usually throbbing, but may also be described as exploding, shooting, or squeezing. Migraine headaches
PATIENT REGISTRATION
Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
Triptan Quantity Limit
*- Florida Healthy Kids Triptan Quantity Limit Override(s) Quantity Limit Approval Duration 1 year Oral Tablets Axert (almotriptan) tablets Relpax (eletriptan) tablets 6 tablets (6.25 mg) 12 tablets (12.5
Understanding Migraines and Treatment Options. Simplified Diagnosis of Migraine. Migraine Prevalence American Migraine Study II
Understanding Migraines and Treatment Options Deborah C. Zajac, RN-BC Center for Headache and Pain Neurological Institute Cleveland Clinic Simplified Diagnosis of Migraine Any person with a stable pattern
HMFP Comprehensive Headache Center Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Instructor in
HMFP Comprehensive Headache Center Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Instructor in Anesthesia and Neurology Harvard Medical School Limited time
Drug Name (select from list of drugs shown / provide drug information) Patient Information. Prescribing Physician
Texas Standard Prior Authorization Form Addendum MOLINA TX MARKETPLACE Botulinum Toxins CL Molina Universal This fax machine is located in a secure location as required by HIPAA Regulations. Complete /
Goals. Primary Headache Syndromes. One-Year Prevalence of Common Headache Disorders
Goals One-Year Prevalence of Common Headache Disorders Impact of primary headache syndromes Non pharmacologic Rx of migraine individualized to patient triggers Complementary and alternative Rx of migraine
Chief, Pediatric Neurology PEDIATRIC HEADACHE QUESTIONNAIRE
Pediatric Neurology Weill Cornell Medical Center New York Presbyterian Hospital 505 E 70 th Street 3 rd Floor New York, NY 10021 Phone: 212-746-3278 Fax: 212-746-8137 Barry E. Kosofsky, MD, PhD Chief,
-On average, on a scale of 1-10 with 10 being the worst pain you can imagine, what is the range of pain intensity?
New Patient Consultation Mia Minen, MD, MPH Patient Name: Sex: Age: Date: Date of Birth: Referring Physician: Which hand do you write with: Right / Left / Ambidextrous Height: Weight: Please briefly describe
Strategies in Migraine Care
Strategies in Migraine Care Julie L. Roth, MD Rhode Island Hospital Assistant Professor, Neurology The Warren Alpert Medical School of Brown University March 28, 2015 Financial Disclosures None. Objectives
Headache Intake Assessment Form
Headache Intake Assessment Form Name: Date: Age: Sex: M F Marital Status Name of Spouse: Name(s) and Age(s) of children: Names & Types of Pets: Education: Occupation: Spouse s occupation: Does anyone in
SOME PEOPLE HAVE MORE THAN ONE TYPE OF HEADACHE -
Dr. Brenda C. Slovin Dr. Erik S. Slovin 203-840-0000 203-840-0011 (Fax) Pain relief without drugs or surgery! www.eliminatemigrainepain.com www.slovinchiropractic.com www.beatingpainandfatigue.com www.endmigrainesnow.com
How did you hear about our practice? Pediatrician referral Self referral (Internet/ Family/Friend) Other
New Patient: PEDIATRIC HEADACHE QUESTIONNAIRE Page 1 Please complete this questionnaire prior to your appointment. It will be used during the appt & become an part of the medical record. Teens should complete
MEDICATION HISTORY FORM
MEDICATION HISTORY FORM Please highlight or circle medications you have tried. Please indicate if they worked (W), didn t work (DW) or if there were any side effects (SE). Over the Counter Aspirin Aleve
Clinical Policy: Triptans Reference Number: CP.CPA.217 Effective Date: Last Review Date: Line of Business: Commercial
Clinical Policy: Reference Number: CP.CPA.217 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important regulatory
ADVANCES IN MIGRAINE MANAGEMENT
ADVANCES IN MIGRAINE MANAGEMENT Joanna Girard Katzman, M.D.MSPH Assistant Professor, Dept. of Neurology Project ECHO, Chronic Pain Program University of New Mexico Outline Migraine throughout the decades
Clinical Policy: Triptans Reference Number: CP.HNMC.217 Effective Date: Last Review Date: Line of Business: Medicaid Medi-Cal
Clinical Policy: Reference Number: CP.HNMC.217 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Medicaid Medi-Cal Revision Log See Important Reminder at the end of this policy for important
Page: 1 of 6. Aimovig (erenumab-aooe) injection, Ajovy (fremanezumab-vfrm) injection, Emgality (galcanezumab-gnim)
Page: 1 of 6 Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Last Review Date: November 30, 2018 Description Aimovig (erenumab-aooe) injection, Ajovy (fremanezumab-vfrm)
Headache Questionnaire
This headache questionnaire is crucial to help us understand you and give you the best care. By completing it, you maximize your time with us at Center for Healing Neurology. This lets us focus on providing
How do we treat migraine? New SIGN Guidelines
How do we treat migraine? New SIGN Guidelines Managing your migraine Migraine Trust, Edinburgh 2018 Callum Duncan Consultant Neurologist Aberdeen Royal Infirmary Chair SIGN Guideline 155 Premonitory Mood
What You Should Know About Your HEADACHE. Learn more about headache types, triggers, and treatments, when to get help, and how to help yourself
What You Should Know About Your HEADACHE Learn more about headache types, triggers, and treatments, when to get help, and how to help yourself Introduction The purpose of this brochure is to give you a
Treatment of Primary Headache Syndromes
Presenter Disclosure Information 2:45 3:45pm Treatment of Primary Headache Syndromes SPEAKER Gerald W. Smetana, MD The following relationships exist related to this presentation: Gerald W.Smetana, MD,
Approach to a Patient with Headache
Approach to a Patient with Headache J.D. Bartleson, MD Professor of Neurology Mayo Clinic College of Medicine 15 th Annual Internal Medicine Conference March 25, 2018 Boca Raton, FL 2014 MFMER slide-1
Index. Prim Care Clin Office Pract 31 (2004) Note: Page numbers of article titles are in boldface type.
Prim Care Clin Office Pract 31 (2004) 441 447 Index Note: Page numbers of article titles are in boldface type. A Abscess, brain, headache in, 388 Acetaminophen for migraine, 406 407 headache from, 369
Outline. Etiology. General information. Definition 4/13/2012
Outline Dr. Susan Fralick-Ball, PsyD, MSN, RN, CH, CLNC PsychMedEd for Advance 2012 Etiology, Stages & Classifications of Migraines Differential Pathophysiology from other Headaches Current Treatment Therapies
Please provide your referring or regular doctor s full name, address, phone number, and fax number. HEADACHE HISTORY
PATIENT INFORMATION Patient Name (Last, First, Maiden) Date of Birth Age Social Security Number Please provide your referring or regular doctor s full name, address, phone number, and fax number. Referring
Case Presentation. Case Presentation. Case Presentation. Truths about Headaches (2017) Most headaches were muscle-tension headaches
Agenda Case presentation Migraine Morphology Primary and Premonitory Phase Secondary Headache Aura Headache Primer on Pain Medication Overuse Headache Case Presentation RT is a 25 year old woman with daily
2008 Migraine Update Migraine Update Migraine Update. Epidemiology. Yousef Mohammad MD., MSc. Epidemiology
2008 Migraine Update Yousef Mohammad MD., MSc Assistant Professor of Neurology Ohio State University Medical Center 2008 Migraine Update Epidemiology 2008 Migraine Update Epidemiology Abortive Treatment
Headache evaluation and management after concussion. Assistant Professor
Headache evaluation and management after concussion Juliette Preston, M.D. Assistant Professor OHSU Headache Center OVERVIEW Introduction Definition Acute post-traumatic headache Red flags Persistent post-traumatic
Adult & Pediatric Patients. Stanford Health Care, Division Pain Medicine
Acute Treatment Strategies in Adult & Pediatric Patients Theresa Mallick Searle, MS, RN BC, ANP BC Disclosures Speakers Bureau: Allergan, Depomed Acute Treatment Strategies in Adult & Pediatric Patients
NEW PATIENT INFORMATION SHEET
Akintomi A. Olugbodi M.D. 301 S. Seventh Ave. Suite 315 West Reading, PA 19611 (484) 869-2817 NEW PATIENT INFORMATION SHEET PLEASE COMPLETE THESE FORMS PRIOR TO YOUR APPOINTMENT AND BRING THEM WITH YOU
Abortive Agents. Available Strengths. Formulary Limits. Tablet: 5mg, 10mg ODT: 5mg, 10 mg 25mg, 50mg, 100mg. 5mg/act, 20mg/act
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Migraine Therapy P&T DATE: 9/12/2017 CLASS: Neurological Disorders REVIEW HISTORY 12/16, 9/15, 2/15, 2/10, 5/07 LOB: MCL
Headache A Practical Approach
Headache A Practical Approach Integrated Pain Symposium December 1, 2017 Alyssa Lettich. MD Neurosciences Institute/Neurosciences Clinical Program Medical Director Headache and Pain Development Teams Disclosures:
Clinical Learning Days November 10, 2017
Migraine Clinical Learning Days November 10, 2017 Alyssa Lettich. MD Neurosciences Institute/Neurosciences Clinical Program Medical Director Headache Disclosures: none Learning Objectives: At the conclusion
Management of headache
Management of headache TJ Steiner Imperial College London Based on European principles of management of common headache disorders TJ Steiner, K Paemeleire, R Jensen, D Valade, L Savi, MJA Lainez, H-C Diener,
You have an appointment with Dr. Santiago Mazuera am
NEUROLOGY DEPARTMENT AT NORTHWEST Northwest Hospital Professional Center 5415 Old Court Road, Street Level, Suite S04 Randallstown MD 21133 Phone: 410-601-9515 // Fax: 410-601-8905 Welcome! This packet
TREXIMET UTILIZATION MANAGEMENT CRITERIA
TREXIMET UTILIZATION MANAGEMENT CRITERIA DRUG CLASS: BRAND (generic) NAME: 5HT1 agonists Treximet (sumatriptan/naproxen sodium) 85 mg / 500 mg tablet FDA INDICATIONS: Sumatriptan/naproxen is indicated
Disclosures. Triptans for Kids 5/16/13
5/16/13 Disclosures Triptans for Kids Amy A. Gelfand, MD GelfandA@neuropeds.ucsf.edu Departments of Neurology and Pediatrics UCSF Child Neurology and Headache Center I receive grant funding from: NIH/NINDS
JEFFERSON HEADACHE CENTER
JEFFERSON HEADACHE CENTER Patient History Name: D.OB: Age: M F Address: Birthplace: Phone: (H) (W) (C) Marital Status: S M W DIV SEP Religion: Race: Referred by: primary care physician other neurologist
NEW PATIENTS' INFORMATION SHEET
NEW PATIENTS' INFORMATION SHEET Please print clearly. Please complete all information so that your claim can be processed quickly and efficiently. Thank you! PATIENT INFORMATION (First) (MI) (Last) Name
Çiçek Wöber-Bingöl HEADACHE UNIT FOR CHILDREN AND ADOLESCENCE
Headache in children and adolescents Çiçek Wöber-Bingöl HEADACHE UNIT FOR CHILDREN AND ADOLESCENCE Dept. of Psychiatry of Childhood and Adolescence Medical University of Vienna, Vienna, Austria Impact
Triptans Quantity Limit Program Summary
Triptans Quantity Limit Program Summary FDA APPROVED INDICATIONS AND DOSAGE 1-13,14,23,24 Agents Amerge (naratriptan) 1, 2.5 tablets Axert (almotriptan) 6.25, 12.5 tablets migraine attacks with/without
Clinical Policy: Triptans Reference Number: CP.CPA.217 Effective Date: Last Review Date: Line of Business: Commercial
Clinical Policy: Reference Number: CP.CPA.217 Effective Date: 11.16.16 Last Review Date: 11.18 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important regulatory
B) If any item or statement on this form applies to you, please check the square corresponding to that item or statement.
PATIENT INSTRUCTIONS FOR COMPLETING THE : A) This detailed questionnaire of your health history is extremely important. Your past health experiences play a major role in developing a successful treatment
I have no financial relationships to disclose. I will not discuss investigational use of medication in my presentation.
I have no financial relationships to disclose. I will not discuss investigational use of medication in my presentation. In 1962, Bille published landmark epidemiologic survey of headache among 9,000 school
Faculty Disclosures. Learning Objectives. Acute Treatment Strategies
WWW.AMERICANHEADACHESOCIETY.ORG Acute Treatment Strategies Content developed by: Lawrence C. Newman, MD, FAHS Donna Gutterman, PharmD Faculty Disclosures LAWRENCE C. NEWMAN, MD, FAHS Dr. Newman has received
Get ahead of the ACHE: Monoclonal Antibodies in Migraine Prevention
Get ahead of the ACHE: Monoclonal Antibodies in Migraine Prevention Amanda Janisch, PharmD PGY2 Ambulatory Care Pharmacy Resident MCHS SWMN, Mankato, MN 2018 MFMER slide-1 Disclosures No financial interest
Tears of Pain SUNCT and SUNA A/PROFESSOR ARUN AGGARWAL RPAH PAIN MANAGEMENT CENTRE
Tears of Pain SUNCT and SUNA A/PROFESSOR ARUN AGGARWAL RPAH PAIN MANAGEMENT CENTRE IHS Classification 1989 (updated 2004) Primary Headaches 4 categories Migraine Tension-type Cluster and other trigeminal
Migraine Management. Jane Melling Headache nurse Mater Misericordiae Hospital
Migraine Management Jane Melling Headache nurse Mater Misericordiae Hospital Migraine facts Among the most common disorders of the nervous system 3 rd most prevalent medical disorder on the planet (lancet
ABORTIVE AGENTS. Average cost per 30 days. Form Limits SEROTONIN AGONISTS $ $ Reserved for treatment failure to either Sumatriptan PA; QL
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Migraine Therapy P&T DATE: 12/11/2018 CLASS: Neurological Disorders REVIEW HISTORY 9/17, 12/16, 9/15, 2/15, 2/10, LOB: MCL
Farjam Farzam, M.D. Pediatric Neurology
Headaches in Children Farjam Farzam, M.D. Pediatric Neurology University of Kentucky Headaches in Children Common complaint in pediatric population. All age groups. 2-3 years old. Teenagers/Adolescents.
IMITREX UTILIZATION MANAGEMENT CRITERIA
IMITREX UTILIZATION MANAGEMENT CRITERIA DRUG CLASS: 5HT1 agonists BRAND NAME: Imitrex 4 mg injection kit or refill (Generic) (sumatriptan) 6 mg injection kit or refill Injection vial (1 dose) 5 mg nasal
10/31/2017 PRIMARY CARE AND HEADACHE DISCLOSURES WHERE DO THOSE WITH HEADACHE SEEK MEDICAL CARE? Primary Care 67%
PRIMARY CARE AND HEADACHE Sonja Potrebic MD PhD Regional Headache Specialist Kaiser LAMC 1 WHERE DO THOSE WITH HEADACHE SEEK MEDICAL CARE? Column1 Primary Care 67% Primary Care Headache Specialty Other
Neurosurgery Associates Headache Intake Questionnaire
Neurosurgery Associates Headache Intake Questionnaire 393 E Town Street, Suite 110 Columbus, OH 43215 First Name: Last Name : Date of Birth: Age: Referring Doctor: Pharmacy: Primary Insurance: Place of
The Use of Botulinum Toxin in the Treatment of Headaches
Mauskop Botulinum Toxin in Headache 377 Pain Physician. 2004;7:377-387, ISSN 1533-3159 An Invited Review The Use of Botulinum Toxin in the Treatment of Headaches Alexander Mauskop, MD Migraine is a disabling
9/2/2010. Pediatric Headache: Learning Objectives: Learning Objectives: Lynn Clark RN, PNP-BC Alicia Haag RN, FNP-C. Objective 7:
Pediatric Headache: A Complex Problem Lynn Clark RN, PNP-BC Alicia Haag RN, FNP-C Learning Objectives: Objective 1: The participant will be able to differentiate between the 4 main types of primary headaches,
Neurologic Disorders: Headache in Children
1 of 12 17/06/2014 7:57 PM Print Close Neurologic Disorders: Headache in Children Sharon Whiting, MBBS, FRCPC Date of revision: February 2014 Headaches occur commonly in children and adolescents. They
Grant s Migraine * Appendix 1
Appendix 1 Grant s Migraine * By virtue of its prevalence and profound clinical effect on the afflicted, it is inevitable that migraine should exert some influence on the course of human history. One especially
Stanley J. Krolczyk DO, RPH Assistant Professor of Neurology University of South Florida College of Medicine Tampa, Florida
Stanley J. Krolczyk DO, RPH Assistant Professor of Neurology University of South Florida College of Medicine Tampa, Florida 1 Trigeminovascular/trigeminocervic al nocicpetive dysfunction Cortical Spreading
Treatments for migraine
Treatments for migraine Information for patients and carers Department of Neurology Aberdeen Royal Infirmary Contents Page About this leaflet Abortive medication for migraine Painkillers Antisickness medication
How could I be having migraine when I don't have a headache?
Migraine Your doctor thinks you may have migraine. Classic migraine attacks start with visual symptoms (often zig-zag colored lights or flashes of light expanding to one side over 10-30 minutes) followed
Anti-Migraine Agents
DRUG POLICY BENEFIT APPLICATION Anti-Migraine Agents Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions
INSTITUTE OF NEUROLOGY
INSTITUTE OF NEUROLOGY HEADACHE AND FACIAL PAIN QUESTIONNAIRE Date / / SECTION 1: PERSONAL DETAILS Surname Date of Birth / / First Name Age Hospital Number Sex Male Female Handedness Right Left Ambidextrous
Initial Pain Questionnaire
Initial Pain Questionnaire Date: Name: Address: Last First Middle Initial Street Address City State Zip Home Phone Cell : Work: Referring Physician: Other Physicians: Age: PAIN HISTORY: What is the main
Chronic Daily Headaches
Chronic Daily Headaches ANWARUL HAQ, MD, MRCP(UK), FAHS DIRECTOR BAYLOR HEADACHE CENTER, DALLAS, TEXAS DISCLOSURES: None OBJECTIVES AT THE CONCLUSION OF THIS ACTIVITY, PARTICIPANTS WILL BE ABLE TO: define
Controlling Migraine Pain
Migraine Stats Controlling Migraine Pain Alan Zacharias, M.D. Associated Neurologists, Boulder Community Health 303-622-3365 Women 15% Men 5% Usually starts in 2 nd and 3 rd Decade Major Impact on days
Vestibular Migraine. Information for patients and carers. Department of Neurology and Otolaryngology Aberdeen Royal Infirmary
Vestibular Migraine Information for patients and carers Department of Neurology and Otolaryngology Aberdeen Royal Infirmary What is vestibular migraine? Migraine is a disabling headache disorder that affects
Disclosures. Objectives 6/20/2018. No disclosures. Tools & Tips for Headache Management in Special Populations: The Young & Old, Pregnant & Lactating
Tools & Tips for Headache Management in Special Populations: The Young & Old, Pregnant & Lactating Lauren Doyle Strauss, DO, FAHS Child Neurology Residency Director @StraussHeadache No disclosures Disclosures
Differential Diagnosis of Headaches
Angela Nelson, MSN, RN, CCRN, ACNP-BC, FCCM, FAANP Acute Care Nurse Practitioner Department of Neurosurgery AANP 2016 National Conference San Antonio, Texas June 21-26 Differential Diagnosis of Headaches
Migraine, Tension, and Cluster Headache: Primary Care for Primary Headaches. Jonathon M. Firnhaber, MD, FAAFP
Migraine, Tension, and Cluster Headache: Primary Care for Primary Headaches Jonathon M. Firnhaber, MD, FAAFP Learning objectives 1. Utilize evidence-based strategies to diagnose patients presenting with
Trigeminal Neuralgia Association UK. Facing pain together TRIGEMINAL NEURALGIA AN OVERVIEW
Trigeminal Neuralgia Association UK Facing pain together TRIGEMINAL NEURALGIA AN OVERVIEW The TNA UK was established to provide support and information to people affected by trigeminal neuralgia and we
Acute Migraine Treatment. Morris Levin, MD Professor of Neurology Director, Headache Center UCSF Department of Neurology San Francisco, CA
Acute Migraine Treatment Morris Levin, MD Professor of Neurology Director, Headache Center UCSF Department of Neurology San Francisco, CA Mo Levin Disclosures Consulting Allergan Supernus Amgen Lilly Royalties
Name: Date of Birth: Neurology New Patient Form
Neurology New Patient Form Date: Primary Care Physician: Medical History: Please circle any health condition that applies to you and specify/comment if needed. If you have any questions, please ask a member
New Patient Questionnaire - Epilepsy
New Patient Questionnaire - Epilepsy Person completing this form: (if other than the patient) GENERAL SEIZURE HISTORY Relationship: When do you think your child had their first seizure? When was the last
Regulatory Status FDA approved indication: Migranal Nasal Spray is indicated for the acute treatment of migraine headaches with or without aura (1).
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.60 Subject: Migranal Nasal Spray Page: 1 of 5 Last Review Date: November 30, 2018 Migranal Nasal Spray
Lost in Translation: Making Sense of Clinical Treatment Guidelines
Lost in Translation: Making Sense of Clinical Treatment Guidelines Charles E. Argoff, MD, CPE Disclosures: Charles Argoff Financial Disclosure: Consultant: Teva, Daiichi Sakyo, Pfizer, Nektar, Purdue,
Headache. Section 1. Migraine headache. Clinical presentation
Section 1 Headache Migraine headache 1 Clinical presentation It is important to recognize just how significant a problem migraine headache is. It has been estimated that migraine affects 11% of the United
Chapter 6 Case Studies
Chapter 6 Case Studies An Interactive Case History of Chronic Migraine: Part 1 A step-by-step guide through the continued diagnosis and treatment of a refractory complex headache patient. New patient Heather
PAIN INFORMATION SHEET
PAIN INFORMATION SHEET PLEASE MARK THE AREAS ON YOUR BODY WHERE YOU FEEL THE SENSATIONS DESCRIBED BELOW. PLEASE USE THE APPROPRIATE SYMBOL & INCLUDE ALL AREAS. **** ==== OOOO XXXX //// ACHE **** NUMBNESS
A case of a patient with chronic headache. Focus on Migraine. None related to the presentation Grants to conduct clinical trials from: Speaker bureau:
Chronic Daily Headache Bassel F. Shneker, MD, MBA Associate Professor Vice Chair, OSU Neurology The Ohio State University Wexner Medical Center Financial Disclosures None related to the presentation Grants
10/13/17. Christy M. Jackson, MD Director, Dalessio Headache Center Scripps Clinic, La Jolla Clinical Professor, Neurosciences UCSD
Christy M. Jackson, MD Director, Dalessio Headache Center Scripps Clinic, La Jolla Clinical Professor, Neurosciences UCSD } Depomed Consultant 2014 to present } Avanir Consultant 2014 to present } Amgen