Personalized Headache Management and Medication Schedule

Patient Information

Name: _________________ Date: _________________ Prescribing Provider: _________________

Daily Preventive Medications

Acute/Rescue Medications (As Needed)

Primary Rescue Medication

• Medication: _________________
• Maximum doses per day: _______
• Maximum doses per week: ______
• Wait time between doses: ______

Secondary Rescue Medication

• Medication: _________________
• Use only if primary medication ineffective after _____ hours
• Maximum doses per day: _______

Headache Trigger Tracking

Common Triggers to Monitor:

• ☐ Stress
• ☐ Sleep changes
• ☐ Missed meals
• ☐ Caffeine
• ☐ Weather changes
• ☐ Hormonal changes
• ☐ Specific foods: ________________

Emergency Warning Signs

Seek immediate medical attention if experiencing:

• Sudden, severe headache ("thunderclap")
• Headache with fever and neck stiffness
• Headache following head injury
• Headache with confusion or weakness

Follow-up Schedule

Next appointment: _________________ Phone number for questions: _________________

Notes