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 bring together top expertise and the state-of-the art resources to appropriately identify and treat underlying causes of your symptoms. We are strongly committed to an active partnership with you by tailoring recommendations to provide the best care possible. Please review this overview of expectations in order to make the most of your experience here at UCHealth. Come prepared: Complete the attached New Patient Headache Questionnaire and bring it to the initial visit. Headache diaries are helpful, for example: https://ahma.memberclicks.net/headache-diaries. Send or bring in referral, clinical notes, relevant imaging studies (MRIs, CTs) prior to your appointment. Fax 720-848-2106 Know the medications you take, check with your pharmacy if necessary. Check with your insurance for any necessary authorizations. What you can expect: Comprehensive evaluation by neurologist specializing in Headache management. Comprehensive Management Plan including: Non-pharmacologic interventions 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 When appropriate, referrals to Outpatient Infusion Center, Pain Clinic, Integrative Medicine, Psychology, Physical Therapy, Social Worker, and other specialties Follow up and procedure visits with physicians or nurse practitioners specifically trained in Headache and pain solutions. Opportunities to participate in clinical trials to advance research in the area of headache and migraine care. The clinic/patient relationship: We encourage you as a headache sufferer 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, we encourage you to be an active participant in your care. Check out with clinic staff after every visit. This is your opportunity to schedule your next appointment, clarify information, and ask questions. Read and follow instructions on your After Visit Summary provided to you at check-out. Please allow one week for non-urgent testing orders. Sign up for the patient portal, My Health Connection, at www.uchealth.org Be respectful to all clinic staff members. Address clinical care questions with your care providers by phone at 720-848-2080 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 Arnaldo DaSilva, MD Alison Furton, FNP-C Chantal O Brien, MD Jeff Reynek, NP-C Jessica Scharein, DNP, NP-C REVISED 12.19.2016 (KF)
New Patient Headache Questionnaire Name: Primary Care Provider UPlease describe your headaches: 1. When did your headaches start? # days ago, # weeks ago, # months ago, # years ago 2. Has your headache changed in pattern? No Yes- when? 3. Did your headache start after a head injury? No Yes - describe 4. Did your headache start after any type of infection? No Yes-describe 5. Was a medical condition associated with the headache onset? No Yes-describe 6. Did your headaches begin when you started or changed a medication? No Yes which one? 7. How many days in a month do you have a headache? How many headache-free days/month? 8. Do you have more than one type of headache? Yes No If yes, answer the following questions about your most concerning headache type. 9. Where are your headaches usually located? Temple [ R L both ] Whole head Jaw Back of the head [ R L both ] Ear [ R L both ] Other Side of the head [ R L both ] Eye [ R L both ] Spreading Front of the head [ R L both ] Neck 10. Your headaches usually feel like: Throbbing/Pulsating Dull Shooting Achy Stabbing Burning Tight Pressure Other 11. How many hours do your headaches last? Shortest Longest Average // OR Constant? Yes No 12. Your headaches are worse in the: morning afternoon evening during the night no pattern 13. Provoking Factors (Triggers, things that bring on a headache) UFood/beverageU: Fasting/skipping meals Chocolate Caffeine Nitrates MSG Aged cheese Alcohol beverages: Wine: [Red White] Other: UPhysical activity/exertionu: Coughing Bending over Exercise Sexual intercourse Other UHormonalU: Menses: Before During After / Pregnancy / Menopause UStressU: Work Home Family Spouse Other: UEnvironmentalU: Allergies Weather changes Altitude Sunlight Other: USleepU: Lack of sleep Too much sleep Change in wake/sleep UOther TriggersU: 1
14. Premonitory symptoms (you experience one or more of these symptoms 1 to 2 days before the onset of headache) Hyperactive Difficulty concentrating Food cravings Other 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 15. 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 UVisualU Blurry vision Spots [bright dark] Tunnel vision Other Flashing lights Loss of vision on one side Wavy lines Zigzag lines Total blindness Double vision USensory and otheru: Numbness/tingling [ R L Both ] Vertigo Other One-sided weakness [ R L Both ] Unsteadiness Speech difficulty Confusion 16. Do you have associated symptoms during your headache? (mark all that apply) Nausea or upset stomach/vomiting Sensitivity to light (prefer a dark room) Sensitivity to sound (prefer a quiet room) Sore/stiff neck Vision changes (blurred, spots, patterns) Eye tearing in only ONE EYE Runny nose in only ONE NOSTRIL Ringing in ears Eye-redness [ R L Both ] Drooping eyelid [ R L Both ] Swelling of eyelid [ R L Both ] Change in pupil [Larger Smaller] Dizziness/vertigo/lightheadedness Imbalance Confusion Stroke like symptoms (facial droop, droopy eye lid, unable to move one arm or leg Sensitivity to smells Difficulty thinking/concentrating/focus Difficulty speaking/slurred speech Increased Urination Anxiety Irritability Memory problems Increased appetite Decreased appetite Diarrhea Constipation Insomnia Sleepiness Numbness/Tingling [ R L Both ] where? Other 17. Headache relieving factors: Lying down Dark quiet room Massage Standing Ice/Cold compress Hot compress Keeping active/pacing Other 2
18. 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) Other: 19. Procedures used (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 Head/Neck injections under X-ray guidance: Yes No Other 3
20. Behavioral and Alternative treatments used Behavioral/Physical therapy Helping? (yes/no) Supplements Helping? (yes/no) Psychologist, therapist Melatonin Physical therapy Riboflavin (vitamin B2) Yoga Magnesium Chiropractic therapy Co-enzyme Q10 Acupressure/puncture Feverfew Biofeedback Petadolex (Butterbur) Other Other 21. 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) Other medication Cefaly, TMS or other device Approximate Dose/day 155-195 units/12weeks How long did you take it for? Weeks/Months/Years 22. 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 Other symptoms associated with headache Other Yes/No Comment 4
23. Do you have any health issues involving? Change in height or weight Skin: including herpes, shingles Eyes (vision) Ears, nose, throat Mouth (dental/orthodontic) Heart (palpitations, murmurs) Lungs (breathing issues/asthma) Stomach (bowel movements) Urination No Yes (describe) Endocrine or reproductive Blood or immune system Muscles or bones Neurologic (seizures or other) Depression Anxiety ADHD Substance abuse Other: No Yes (describe) 24. Core Health Questions and occupation UMeals How is your appetite? excellent good okay not good awful Do you skip meals often? Yes No How many 8oz glasses of water, juice, or milk do you drink per day? glasses per day Do you drink caffeinated beverages (soda, coffee, or tea)? Yes No; if yes how many servings per day? USleep How long does it take you to fall asleep? minutes How many hours do you sleep a night? hours Do you have any problems falling asleep? Yes No Do you have any problems staying asleep? Yes No Do you snore? Yes No Have you ever been told you have sleep apnea? Yes No Do you grind your teeth? Yes No UExercise How often do you exercise? days per week What do you do for exercise? How long do you typically exercise? minutes URelaxation How do you relax? Do you wish you had more time to relax? Yes No UOccupationU 5
MIDAS DISABILITY ASSESSMENT This questionnaire is used to determine the level of pain and disability caused by your headaches and helps your doctor find the best treatment for you. INSTRUCTIONS: Please answer the following questions about all your headaches over the last 3 months. Write your answerit must be Uone numberu, not a word or a range - in the box next to each question. Write zero if you did not do the activity in the past 3 months. If you don t keep a headache calendar, provide your best estimate. # of DAYS 1. On how many days in the last 3 months did you miss work or school because of your headaches? (If you do not attend work or school enter zero in the box.) 2. How many days in the last 3 months was your productivity at work or school reduced by half or more because of your headaches? (Do not include days you counted in question 1 where you missed work or school. If you do not attend work or school enter zero in the box.) 3. On how many days in the last 3 months did you not do household work because of your headaches? 4. How many days in the last 3 months was your productivity in household work reduced by half or more because of your headaches? (Do not include days counted in question 3, where you did not do household work.) 5. On how many days in the last 3 months did you miss family, social, or leisure activities because of your headaches? Total (Questions 1-5) A. On how many days in the last 3 months did you have a headache? (If headache lasted more than one day, count each day.) B. On a scale of 0-10, on average, how painful were these headaches? (Where 0=no pain at all, and 10=pain which is as bad as it can be.) Office use only 0-5 Little to none, 6-10 mild, 11-20 moderate, 21-40 severe, 41+ very severe ALLODYNIA QUESTIONNAIRE (ASC-12) How often do you experience increased pain or an unpleasant sensation on your skin during your most severe type of headache when you engage in each of the following? Does not apply to me Never Rarely Less than half the time Half of the time or more Score: 0 Score: 0 Score: 0 Score: 1 Score: 2 Combing your hair Pulling your hair back (e.g., ponytail) Shaving your face Wearing eyeglasses Wearing contact lenses Wearing earrings Wearing a necklace Wearing tight clothing Taking a shower (when the water hits your face) Resting your face or head on a pillow Exposure to heat (e.g., cooking, washing your face with hot water) Exposure to cold (e.g., using an ice pack, washing your face with cold water) Add columns Sum of total scores Office use only: 0-2 none, 3-5 mild, 6-8 moderate, 9+ severe allodynia 6
PATIENT HEALTH QUESTIONNAIRE (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things 2. Feeling down, depressed or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless than you have been moving around a lot more than usual 9. Thoughts that you would be better off dead or of hurting yourself in some way Add columns Not at all Several days More than half the days Nearly every day Score: 0 Score: 1 Score: 2 Score: 3 Sum of total scores If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult Office use only: 5 Mild, 10 moderate, 15 moderately severe, 20 severe GENERAL ANXIETY DISORDER SCALE (GAD-7) Over the last 2 weeks, how often have you been bothered by the following problems? 1. Feeling nervous, anxious or on edge 2. Not being able to stop or control worrying 3. Worrying too much about different things 4. Trouble relaxing 5. Becoming easily annoyed or irritable 6. Feeling afraid as if something awful might happen Add columns Not at all sure Several days Over half the days Nearly every day Score: 0 Score: 1 Score: 2 Score: 3 Sum of total scores If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult Office use only: 5 Mild, 10 moderate, 15 moderately severe, 20 severe 7