Headache

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DiagnosisChoose oneTitle

Red flags presentChoose any

Red flags absentChoose any

ExamChoose one

ImagingChoose one

Likely contributorsChoose any

PlanChoose any

Additional planChoose any

NeurologyChoose one

DispositionChoose one

Follow-upChoose one

Follow-up reasonChoose anyJoins the line above

Counseling paragraphChoose oneParagraph

CounselingNot in the note with these choices

Discussed the need for emergency evaluation today. Caregiver expressed understanding and agreement with plan. Answered all questions.

Note when inserted as is

Headache
• No sudden severe onset, waking from sleep or morning vomiting, a worsening or changing pattern, neurologic symptoms, fever with neck stiffness, headache with coughing or straining, or constant pain without breaks
• Neurologic exam reassuring
• Head imaging not indicated given a reassuring history and neurologic exam
• Headache hygiene reviewed with an emphasis on sleep, hydration, regular meals, and limiting routine caffeine
• Recommended tylenol or motrin at headache onset, with fluids and rest in a dark, quiet room
• Recommended a headache diary to track frequency, triggers, and what helps
• Follow up if not improving

Most headaches in children are not caused by a serious problem and improve with healthy routines. Recommended supportive care with tylenol or motrin at the start of a headache, with an emphasis on regular sleep, fluids, regular meals, and limiting caffeine and pain medicine to a few days a week. Return precautions given including a sudden severe headache, headaches that wake the child from sleep or come with vomiting, weakness, numbness, vision changes, trouble walking or talking, fever with a stiff neck, headaches that are becoming more frequent, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

Headache type as title (headache, tension-type, medication overuse, chronic daily)
Red flags present or absent (sudden severe, waking or morning vomiting, worsening pattern, neurologic symptoms, fever with stiff neck, cough or straining)
Neurologic exam reassuring
Fundoscopic exam, papilledema
Imaging not indicated vs MRI for red flags
Contributors (sleep, meals, fluids, screens, stress, caffeine, pain medicine overuse)
Headache hygiene
Acute OTC plan (tylenol or motrin, fluids, dark room)
Headache diary
Limit pain medicine; stop for overuse

Show 5 more

School letter
Therapy or CBT for stress
Eye exam
ED for red flags
Follow-up as needed; recheck with diary; after MRI

Return precautions in the template

a sudden severe headacheheadaches that wake the child from sleep or come with vomitingweaknessnumbnessvision changestrouble walking or talkingfever with a stiff neckheadaches that are becoming more frequent

Sources

Few formal guidelines cover this topic, so the template also leans on expert opinion.