T,ic:-834006,HTREUE

Q
P
GOVERNMENT OF INDIA

MINISTRY OF HEALTH&FAMILY WELFARE

CENTRAL INSTITUTE OF SYCHIATRY, KANKE, RANCHI-834005,

HEADACHE CLINIC
cRE No.
I IA Deted O L
***********''**'****

Nerme (Block Letters)..

*******4****it********* *****
*************
- **********'***° .Age/Sex.. ***** **** *
**

Father'/Husband's Neme...
********'****************4* ***
*********************************************** *******

*'***'******'****"****************.***************.
Kddress :Present.. **********'*
***********
****************'**********'*'

***********°*******'**************************
a**************
'
*******
***e
*****'*****'*********'*************.
.... STD Code....
Telephone..
'*'****' ********'*** *****************
d*********** -********

****************************************-****'***********'******.
Permanent..
**********'*. *******************.
****'***********°*****************
*
**"'****'**.* * *

tatus:Sngle/Marriad/Separeted/Divorced/Deserted/Widow/Widower/Remarried/Polygamous.

amerBusiness /ExecutiveProfeeslonel'Housewite/Famillal Vocatlon"/Studer/None/Retred"

Dccupatlor
Others: "Specity: . ****
********************************"*

Rellglon HinduMuslirm/Chrietian/Slkh/Others "Specify: **+*************

***** ********** *****

. . T r l b a l : Yea/Nob
Mothe: Tongue: Hind/Urdu/BengallTelugurOritya/Othere:"Specifly:
Educatlo»n :Ni3 Ro./Ptimary/Middle/Secondary/ Inter/araduate/ Technical"/P.a."Profesaiona
Speclfy
Resldence Rural/Urban/Suburban. Kms./201-300 Kms.J
Kms./s1-100 Kms./101-200
istance :LocabUpto 10 Kms.Upto 11-30 Kms./31-50
301-400 Kms./Beyond 400 Kms.
ncome Monthly: (From All Sources) Be v 500/5o0-1000/1001-2000/2001-3000/3001-5000/5000-7000/
7001-9000/9001-12000/ 001-15000/15001-20000/Beyonct 20000.

************
***********

Source of Referrel 1. Set, 2. Organization 3. Dr." Spocily

********A***** **.*****

***********'***'****************'*****°********

**** *********** ***

Referral Letter No.:. ** ******* ******

ICD Code: ************'**°*****"
Provisional Diagnosis ************°******°*.*' "

at the OPD)

Final Diagnosis ****** '****' ************************''***" ICD Codee: ***°****'"****

Date

Subsequerit Change in Dlagnosls, f any : . . 4*****'***°*******"**'**'"****'*" ******"

ICD Code:.
*******4******"
Date: -..**

Order S of Mental Health Act 1987.L. Act 1912

f adrnitlecd Type: Voluntary/On Reception
. .

Independent/Govenment Quota Bed'r peclfy. *********** ***

.ol
DOA ***** ************** * *********'****** ***°***************************

Diecussed With
ase Notes Written By
 HEADACHE CLJNIC AISTORY SHEET

Informant

Complaints
Duration(Chronlogical):

History of present complaintls:

Headache Clini c/
 History of Headache:
Find out whether the
compläints are
Aciite/uDacute/Chroic
ACute: (Meinitis, cephal1t.s,. Subarachn vid heom
Neuritis. inusitis. 'rrolh-age, S.tdurl lheamatoma, Glaucoma, Optic
Hypertenson. Pheochromacynoma.
Sulbacute Subdur.l Hean.atoma,
('ercbral avscess,urnour, Intracranial silus
tihrombosis, Benign intracranial
hyperterusion, Giant ceil arteritis
Hys»uaroidisnu,
Chroaic: Migraine, Muscle contraction Hyperparathyroidisn1).
headache, Melabolic, Systcn:ie,
Malign ant disorders).

ONSET: Earliest memory oi head.cle, whetiver

tollowed a tra imatic episcde, First event or recurrent,
Charactcr remanei sare or
c'hanged, Age al td:e on:er.))

FREQUENCY: Earlier:
Curen
DURATiON :
(A verage, shortest anú kngest dur.tion of headache).

INTENSITY : (Usul, ii, ted

oy restricor sf activilies)
Mild Minma! restriion
2. Molerate
Mediun restrictnn
3. Severe
gmiticant restrict.o:1
4.
Incapcitaing :Total restricio
LOCATION (Where starts. radtates ard settles)

QUALITY: {Acng, horing, kurning. expanding. Pnawing. pivrcing. pounding ,ressing, s-ueczing. stabbing.
throbbing
PRECIPITANT :1Alcoho, ch:nge in baroinctripressuse, iending, be igh: "ighis, che wing.
"atigue. food.
eou ghing, exertion,
head jarriny, hunger, heud noise, imearc:ie, menopause,
inersrruat ior, odors. position, sexual activity
p babiis, sneezing. siaining. stress, touching).

AMELIORATOR : (Stl I.ied, oni:ing. ete., uhat is done t: rsiev. die hniaclhe. includ; here the
posturs adopicd ml usedriys, wirch).

H 2dche Clinic/2
 cet, red eyes, lad
jaw, coid
1anis and
Cal oedenma,
ASSOCIATED SYMPTOMS: (Erux, chil,ess
eVer, Ihusling, lachryination, mvalat:*.
nasat congesiion,
nused, pallor, O:yurea,
rhnorrhea, scalp
rhnon

E
endcrnes5. vOininig).

TYPES OF HEADACHE
crent types cf headache exist. give uciails thercof separaiciy

Belore, aflcr an turing he attack).(Amnesu ataxia

NEUROLOGICAL ACCOMPANIMENT nearng ioss hemi
dysphagia, dys,hsia,
dysarthria. ight hr:aledncss oss
btndness, blurred vision. contusion, aiplop1id. e,ag.
cordinilion,
ticld Celects, impaired thought process, iC posIS, pupillary
C ptic changcs,
uinb cxlreunity.
parEs's,
Changes
oDsCUralion, Vonitin
COnsCiOusness, loss depth perceptior. mon trin;itus, vcrtipo,
viSU.U )
teichops..,
lng sconas, spinchier disturbances,

PAST HISTORY :
Psychiatric : (Symptoms, ircaiiet. probat' :,SiS

duit illnes., imurzalion, peralion,

Medical (General health, chitdnood illness, :najor
ronchial astina elc.
ulcer
ROspitaliation,concurrent illness, hyperacidly, pepic

(Aspirin, Penie:llhn, food allerg::s elc.)

Allergies :

vf tabiers per vec

Prescribed and over the counter drugs : (rccen iicelo atio anu no.

Current or

meimber having similar symjtcIS, r hist'y of nerveus ad enal diso.u

FAMILY HISTORY : Airy dise st.
kidney disease, t o i d
discase.hyperiension, sirnkcs abeies,
relatives having hisiory of ieadiiche, Ieearl
cancer, iub:rculosis).
hlood dlyscriasis.

Hedeche Ciie'
 PERSONAL HISTORY : (Honc enviror1ment, abusei
divorcc or separation, as child, neglec ted by parents, parental discord,
cducation, ocr.upation, uncmploy1er!, adiustn.ent
and liabilitics in family and work ng
pulacc, reniuneration

PERSONAL HABITs

PERSONALITY TRAITS: (Anxious, histrionic,

obsessional, anti-soe ial ctc.)

SYSTEM REVEW: ( Enquire in all cases

abuut, general const itulional
pr:biems, eye siraIIs, skeletal iystem ymptoms. car, nuse and throat
s

G.I disiurbances, specially about cervical spincs, enderinsu, ihyroid,

heampoetic disorcders, respiralory, cardic,
genitourinary or
reurological potlems).

EXAMINATION
APPEARANCE & BEHAVIOUR

CONSCIOUSNESS:

ATTENTION. CONCENTRATION, MEMORY, ORIENTATION.

MOOD (enquirc specilically abou' depression).

THOUGHT: (ldeas o: guilt, suicide, hypochk ndriac delusion, etc.)

Headache Clinic/4
 PERCEPTUAL DISORDER
OBSESSION, POCHONDRIASS, PHOBIAS, PANIC.
ETC.

GENERAL EXAMINATION
Temperature Pulse 3.P

Respiration ********
Height Weght ...

Skin (lesion, rashes, pigmentation etc.

Systenms: (Giyepositive tindings, iL anY)

1. CVS
2 Abdomen
3. Thyroid
4. Cervical Spine (Tenderness, mobility, extension, tlexion, rc tation)
S Temporomandibuiar Joints (Tenderness., limited opening. maiocclusi n
6. Head (size, shape)
8. Skuil (Tenderness, depression, protuberaice, auscultation)
9. Carotid. temporal, occipital arteries (palpate and auscultate).
10. Orbital bruits:
1. Sinus-tenderness : (inaxillary, fronial, ethmoidal)

Neurological Exanination
Cranial Nerves

III. IV, VI

I. (Acuity. Field, Colour Vision, Optholmoscopic Findings)

V. (Opthalmic, mandibular, maxillary branches)

VII, VIII,

IX. X, X1. XII

Headache Clinic:s
 GAIT
COORDINATION:
MOTOR SYSTEM:
REFLEXES

SENSORY SYSTEM1
CEREBELLAR SIGNS
DYNAMIcS
Role headache
play in liis life
2. Is the invalid role
useful ?
3. What the pain a.low the
4 What the pain
paient toavoid?
pernmits him lo do
(make cdemands on otters
Is the patient playing a rma:iyr's ?
role ?

DIAGNOSTIC FORMUL ATION:

DIFFERENTIAL DIAGINOSIS:

DIAGNOSIS CODE:
(Internatio, u! Stx'icty for Heaulach: Classitication

iieadache Climc/6
 MANAGEMENT:
(A) INVESTIGATIONS:

(B) TREATMENT ADVISED:

F a i a c e Cln ic'7
 DIAGNOsTIC CRITERIA OF PRIMARY
HEADACHE
1.1Migraine Without Aura
A. Atleast 5 attacks fulfilling B-D
B. Headache attacks lasting 4.72 hours (untreated
C. At least 2 of the
following characteristics
or
unsuccesstiully treated).
I. Unilateral locaticn.
2. Pulsating quality.
3. Moderate to severe
intensity.
4. Aggravation by' walking upstairs or similar physical activity
following During headache al leist of

i. nausea and/or vmiting.

ii. Photophubia ur
phonophobia.
1.2Migraine with aura:
A. At least 2 attacks fulfilling B
B. At least 3 ol 4 characteristics
I. One or more
fully reversible aura symptom:s indicatig focal cerebra!, corticzal
brain stem tysfu1nction. ånd or
2. AUeast one aura
symptom develop gradually over more than 4 minutes, or two or mere
symptoms occur is proportionately increase.
3.NOura sympiom lasts for mere than 60 minutes. If more than one aura is presert tne
accepted Juration is proportionately increased.
4. Heauache follows aura with a free intervai less than 50 1minutes (it ma y also begin betore
or
simeltaneously with aura).

2.1Episodic Tension Type Headache:

A At least 10 pre vious episodes fulfilling criieria B-D, numler of days witih suci headáche is
180 day/yr.
B. Headache lasting srom 30 minutes to1
days.
C. Atleast 2 of the
followiags
1.Pressing/tightening (non-pulsating) qualityY
2. Mild to moderate irntensity.
3. Bilateral
4. No aggravation by walking or similar physical activity.
D. Both of the foliowings :
1. No nausea/vomiting
Photopliobia/phonophobia absent or only one of thein present.

Headaehe Clinic/8
 3.1Cluster Headache
A. At least 5
atlacksfulfilling criteria B-D
B.
Sever unilateral. orbital, supre ital, ant/or temr.ora
pain lasting 15-180 minutes
. Headaclie with one of the unued. Je.
fo:lowing signs o e ipsilateia"
1 Conjuctival injections
2. Lacrymation
3. nasal congestion.
4. Rhinorrhoea
5 Forehead and facial sweating t. mioss
7. Ptosis
8 Eyelicd oedema
D. Frequency One every other dav to 8 every day.

INTERNATIONAL CLASSIFICATION OF HEADACHE

Classifsication of prinary heada.he
Miyraine
1.
Migrane without aura
i.2 Migrane with aura
1.21 Migraine with typcal au.
1.2.2 Miyraine with typical äu
1.2.3 Familial hemiptegic :igtan
1.2.4 Basilar migraine
1.2.5 Migraine aura without headache
1.2.6 Migraune with acute on*:* ar
1.3
Optholn:oplegic Migraine
1.4 Retinal Migraine (Retinal

.5Childhood periodic syndronies that may be precursor to cr associaied wtiii Migraine:

i.51Benign Paroxysmal headach or childhood

1.5.2 Alternating hemiplegic of chilkibood
1.6Complication of Migraine
1.6.1Status MigranousA
1.6.2Migranous infarction
1.7Migranous disorder n
fulfilii t? above eriteria.
2.Tensin 'Type Headache
2.1Episdi: tension type hcadache
nuscles.
2.1.1Episodic tension type heitdacle associated with disorders of pe ricranil
2.1.2Episodic ension type headache not associated with disoi ders of' pericr anial muscies.

2.2Chronie Tension Type Headache

2.2.1Associated with disorder of pericranial niuscles.
2.2.2Nor associated with disorder of pericranial muscles.
2.3Headache of tensin type not iuiilling the ahove criteria.

Heahe Clinic/9
 3.Cluster Headache and
3.1Cluster Headache Chronic Paroxysmal iHemicrania:
3.1.1Cluster Headache
Periodicity undetermined
3.1.2Bpisodic cluster headache
3.1.3Chronic cluster headache
3.1.3.1Unremitting from onset
3.1.3.2Evolved from episolic
3.2Chronic Paroxysmal Hemicrania
3.3Cluster Headache not
fulfiiling the above criteria.

Heudache Cti, 7ics10

4.Miscellaneous Headache unassociated with structural lesion:
4.1 Idiopathic stabbing headache
4.2External compression heada:he
4.3Cold stimulus headache
4.3.1External application of cold stiinulus
4.3.2Ingestion of cold stimulus
4.4Benign Cough Headache
4.5Benign exertional Headache
4.6Headache associated with sexual activity:
4.6.1Dull type
4.6.2Explosive iype
4.6.3Postural type

DISEASES THAT MAY PRESENT AS HEADACHE

Febrile illnesses
Intections
Pheochromocytoma
Malignant hypertension
Systemic lupus Erythromatosus (SLE)
Vasculitis (Temporal arteritis, PAN)
Fibromyalgia
Sleep Apnoea
Chronic renal Failure
Hyperthyroidism
Hypothyroidism
Hyperparathyroidism
Adernal Deficiency syndromes
Polycythemia
Hyponatremia
Hypoxia

iedache Clinic/11