Come prepared: What you can expect:
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1 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 state-of-the art resources to identify and treat underlying causes of your symptoms. We are strongly committed to an active partnership with you to achieve the optimal care. Please see this overview of expectations to make the most of your experience at UCHealth. Come prepared: Complete the attached 4 page New Patient Headache Questionnaire and bring it to the initial visit. Headache diaries are helpful, for example: Send or bring in referral, clinical notes, imaging tests (i.e. MRIs, CTs) prior to your appointment. Fax Know the medications you take, check with your pharmacy if necessary. Check with your insurance for any necessary authorizations. What you can expect: Comprehensive diagnostic evaluation by neurologists specializing in Headache and Pain Comprehensive management plan including: Non-pharmacologic: i.e. relaxation, trigger management, exercise, sleep, and diet recommendations. Pharmacologic therapies: preventative and abortive medications - avoid misuse. Procedures: Botox injections for chronic migraine, nerve blocks, trigger point injections, other. Referrals to Integrative Medicine, Outpatient Infusion Center, Pain Clinic, Physical Therapy, Psychology and other specialties as well as inpatient treatment, as appropriate. Follow up and procedures with physicians or nurse practitioners with expertise in Headache and Pain solutions for up to one year at which time we will re-evaluate for further management of symptoms. Opportunities to participate in clinical trials to advance research in the area of headache and migraine care. The clinic/patient relationship: we encourage you to stay connected with your specific life goals that are defined by your own values and needs, and not by headache pain. To assist us in helping you, please be an active participant in your care. Read and follow instructions on your After Visit Summary provided at check-out. Sign up for the patient portal, My Health Connection, at Be respectful to all clinic staff members. Address clinical care questions with your care providers by phone at or via My Health Connection. All questions are taken seriously and will be triaged and answered professionally. Please allow appropriate time for answering symptom calls (24-48 hours) and non-urgent questions (24-72 hours). As always, in the event of a life-threatening situation call 911. Thank you, again, for allowing us to participate in your health care. We look forward to working with you! Marius Birlea, MD Haley Burke, MD Chantal O Brien, MD Alison Percowycz, NP Jeff Reynek, NP Jessica Scharein, DNP Whitney Tice, NP 1
2 New Patient Headache Questionnaire Name: Primary Care Provider 1. When did your headaches start? # days ago // # weeks ago // # months ago// # years ago 2. Did your headache start after a head injury? No Yes -describe 3. Did your headache start after an infection or other medical condition? No Yes-what? 4. Did your headache begin when you started or changed a medication? No Yes -which one? 5. Has your headache changed in course/pattern? No Yes- when? 6. How many days in a month do you have a headache? How many headache-free days/month? 7. How long do your headaches last? Shortest Longest Average // OR Constant? Yes No 8. Your headaches are worse in the: morning afternoon evening during the night no pattern 9. How severe is your headache (from 0 - no pain at all to 10 - worst possible pain)? Average _Worst 10. Where are your headaches usually located? Temple [ R L both ] Whole head Face [ R L both ] Back of the head [ R L both ] Ear [ R L both ] Side of the head [ R L both ] Eye [ R L both ] Changing location Front of the head [ R L both ] Neck 11. Your headaches usually feel like: Throbbing/Pulsating Dull Shooting Achy Stabbing Burning Tight Pressure 12. Provoking Factors (triggers, things that bring on a headache) Environmental: Weather changes Altitude Sunlight Allergies : Food/beverage: Skipping meals Caffeine Processed meet MSG Aged cheese Chocolate Alcohol beverages:- Wine: [Red White] : Hormonal: Menses: Before During Late cycle // Pregnancy // Menopause Physical activity/exertion: Bending over Exercise Sexual intercourse Coughing Sleep: Lack of sleep Too much sleep Change in wake/sleep Stress: Work Home Family Spouse : Triggers: 2
3 13. Premonitory symptoms (you experience one or more of these symptoms 1 to 2 days before the onset of headache) Hyperactive Difficulty concentrating Food cravings Depressed feeling Sensitive to light Increased appetite Irritability Sensitive to sound/noise Decreased appetite Feeling sluggish Difficulty with speech Increased urination Dizziness Excessive yawning Neck pain/stiffness 14. Aura: No Yes- If you have any of the symptoms below, they usually last: minutes and occur about: minutes before pain starts during the head pain after the head pain; without the head pain Visual Blurry vision Spots [bright dark] Tunnel vision Flashing lights Loss of vision on one side Wavy lines Zigzag lines Total blindness Double vision Sensory and other: Numbness/tingling [ R L Both ] Vertigo/unsteadiness _ One-sided weakness [ R L Both ] Confusion Speech difficulty Smell changes 15. Do you have associated symptoms during your headache? (mark all that apply) Nausea or upset stomach/vomiting Eye tearing in only one eye [ R L ] Sensitivity to light (prefer a dark room) Runny nose in only one nostril [ R L ] Sensitivity to sound (prefer a quiet room) Eye-redness in only one eye [ R L Both ] Sore/stiff neck Drooping eyelid only one side [ R L Both ] Vision changes (blurred, spots, patterns) Swelling of eyelid only one side [ R L Both ] Confusion Change in pupil only one side [Larger Smaller] Difficulty thinking/concentrating/focus Ringing in the ears Difficulty speaking/slurred speech Sensitivity to smells Insomnia Decreased appetite Sleepiness Increased appetite Irritability Constipation Anxiety Diarrhea Memory problems Imbalance Dizziness/vertigo/lightheadedness Increased Urination Numbness/Tingling [ R L Both ] face, arm, leg? Weakness [ R L Both ] face, arm, leg? Restlessness _ 16. Headache relieving measures: Lying down Dark quiet room Massage Standing Ice/Cold compress Hot compress Keeping active/pacing _ 3
4 17. Which Acute/abortive medications (medications taken to stop a headache) have you used? Acute/abortive medication On average, how many days per week? Helping? (YES/NO) Acetaminophen (Tylenol) Almotriptan (Axert) Aspirin Baclofen (Lioresal) Celecoxib (Celebrex) Cyclobenzaprine (Flexeril) Diclofenac (Cambia) Dihydroergotamine (Migranal, DHE) Diphenhydramine (Benadryl) Eletriptan (Relpax) Excedrin Fioricet, Fiorinal Frovatriptan (Frova) Ibuprofen (Advil/Motrin) Indomethacin (Indocin) Ketorolac (Toradol) Lidocaine nasal spray Metaxalone (Skelaxin) Metoclopramide (Reglan) Midrin (Duradrin, Epidrin) Naproxen (Naprosyn, Aleve) Naratriptan (Amerge) Ondansetron (Zofran) Prochlorperazine (Compazine) Promethazine (Phenergan) Rizatriptan (Maxalt) Sumatriptan (Imitrex) Tizanidine (Zanaflex) Tramadol (Ultram) Vicodin, Codeine, Demerol, Percocet Zolmitriptan (Zomig) : 18. Procedures tried (check all that apply): Helped? Yes/No Occipital nerve blocks: R L Both Auriculotemporal nerve blocks: R L Both Supra-orbital/Supra-trochlear nerve block: R L Both Trigger point injections Head/Neck injections under X-ray guidance: Yes No Botox injections: 4
5 19. Behavioral treatments and supplements Behavioral/Physical therapy Helping? (yes/no) Supplements Helping? (yes/no) Psychologist, therapist Physical therapy Yoga Chiropractic therapy Acupressure/acupuncture Biofeedback B2 Vitamin (Riboflavin) Co-enzyme Q10 Magnesium Marijuana Melatonin Petadolex (Butterbur) 20. Which Preventive medications or devices (taken daily/regularly to prevent headaches) have you tried? Preventive medication Amitriptyline (Elavil) Botox injections (Onabot. Tox. A) Candesartan (Atacand) Gabapentin (Neurontin) Lamotrigine (Lamictal) Lisinopril (Zestril) Metoprolol (Lopressor) Methylergonovine (Methergine) Nortriptyline (Pamelor) Pregabalin (Lyrica) Propranolol (Inderal) Topiramate (Topamax) Valproic Acid (Depakote) Venlafaxine (Effexor) Verapamil (Calan) Zonisamide (Zonegran) medication Cefaly, TMS or other device How long did you take it for? Weeks/Months/Years 21. Have you needed to go to the emergency room (ED) for headaches? Yes No; If yes, how often? What makes/made you decide to go to ED? Lack of acute/abortive medications at home Lack of pain relief with home medications Nausea/vomiting Fear of some dangerous condition Lack of outpatient primary care or headache care provider Worsening or new headache symptoms associated with headache Yes/No Comment 5
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
Thank you, again, for allowing us to participate in your health care. We look forward to working with you!
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