Headache Intake CL

RE: 

IDENTIFICATION:
The patient was seen at the neurology clinic at Regional Headache and Neurology Specialists on November 2, 2025, for evaluation of recurrent headaches.

HISTORY OF PRESENTING ILLNESS:
The patient described headaches that began in July, occurring in the back of the head and around the eyes, with pain alternating sides or affecting both sides. The pain can start in the back and move forward, or be localized to the front or back. Headaches are described as sharp and sometimes shooting, lasting between 5 and 15 minutes per episode, and occurring multiple times throughout the day. The patient experiences nausea with approximately 80% of episodes, as well as blurry vision and dizziness. There is no clear trigger, though tiredness may contribute. The headaches do not wake the patient from sleep. The patient denies head trauma, car accidents, or whiplash injuries. There is no sensitivity to touch at the back of the head. The frequency of headaches varies, with periods of increased severity and periods of remission, but at least one headache occurs daily. The patient previously tried indomethacin for two days, which was effective but caused intolerable side effects.

PAST MEDICAL HISTORY:
Not available.

MEDICATION:
The patient is not taking any medications on a regular basis. Indomethacin was previously prescribed and taken for two days, but discontinued due to side effects.

FAMILY HISTORY:
Not available.

SOCIAL HISTORY:
Not available.

EXAMINATION:
On examination, there is no tenderness to palpation at the back of the head, though the patient reports some pressure when palpated. No other abnormal findings were discussed.

CRANIAL NERVE EXAM:
Not specifically documented.

MOTOR EXAM:
Not specifically documented.

SENSORY EXAMINATION:
Not specifically documented.

COORDINATION:
Not specifically documented.

GAIT EXAM:
Not specifically documented.

ASSESSMENT AND PLAN:
The patient presents with recurrent, short-duration, sharp headaches with associated nausea, blurry vision, and dizziness. The headaches are variable in location and frequency, with no clear trigger and no evidence of trauma. Indomethacin was effective but not tolerated due to side effects.

Plan:
- Administer a nerve block injection at the back of the head to attempt symptom relief.
- Order a computed tomography scan of the cervical spine to evaluate for possible misalignment contributing to symptoms.
- Schedule a follow-up phone call in two weeks to assess response to the nerve block.
- If no improvement, consider initiation of alternative medications.
- Patient education provided regarding expected numbness after the injection and follow-up instructions.

I will follow up with the patient by phone in two weeks to assess response to the nerve block and review the results of the cervical spine CT. Further management will be based on the patient's response.

Alexis Lee, M.D.
Neurology
Regional Headache and Neurology Specialists