Migraine SOAP Note


Identifying Information:

Patient: C.T. 38 y/o WF.

DOB: 03/15/1975

Visit: 10/4/2013, 1000

Chief Complaint: “I am here for an evaluation of my headache.”

HPI: C.T. a 38 y/o white female presents to the clinic for an evaluation of a headache. The pain is a throbbing sensation that is located in the temporal region and is an 8 on a scale of 1-10. The pain started a few hours ago while cooking breakfast. She has noted nausea with sensitivity to light. She has had headaches like this in the past. She states the headaches are usually less than one per week, but not as severe. There has not been any change in the frequency of her headache. She does not know of any aggravating factors. Ibuprofen and rest in a dark room resolves the pain. She denies any fever, hearing loss, or neck pain.

Medical HX: Pt was diagnosed with high cholesterol and type 2 diabetes 5 years ago, both are well controlled with medication, diet, and exercise. She is currently No other childhood or adult diseases, and immunizations UTD. She received the flu vaccine 10/2013. No psychiatric history.

Surgical HX: No surgical history.

OBGYN: G-2 T-2 P-0 A-0 L-2

Medications: Ibuprofen 400 mg by mouth every 6 hours as needed for headache (last taken

6 hours ago)

Lipitor 20 mg by mouth daily (last taken this morning)

Amaryl 2 mg by mouth every morning (last taken this morning)

Allergies: NKA

Personal/social HX: Pt is married and lives with her husband and 2 children, all girls, ages 8 and 5. Lives in own home near her parent’s on rural property. Patient works approximately 20 minutes away at a car dealership as an accountant. Her husband is a self-employed contractor. They both graduated from LSU 15 years ago. C.T. states she works 2-3 days a week, 12-hour shifts. Family attends church on a regularly and has a good support system. The family is very active in the gym close to their home and eats healthy. C.T runs 4 miles at least 5 times a week.

Drugs, Alcohol, or Smoking HX: No illegal drug use, no alcohol, or tobacco use.

Family HX: Positive for diabetes and HTN in mother and father died of colon cancer 3 years ago at the age of 58. No family history of kidney disease, anemia, epilepsy, or mental illness.

Source of information: Patient, seems reliable.

SUBJECTIVE: Pt presented to the clinic today with a headache, that has a throbbing sensation located in the right temporal region. Rates the pain 8 on scale of 1-10. Pain started a few hours ago, and she has noted nausea with sensitivity to light. Has had headaches like this in the past, but usually less than one per week. Never this severe. No inciting factors and there has been no change in the frequency of her headaches. OTC analgesics help rid the headache.

Review of Systems:

General: Reports being “as healthy as she can be.” Denies fever, chills, recent weight gain or loss, weakness, or fatigue. States her last physical exam was in 2012.

Skin, hair, & nails: Denies any changes in skin, hair, and nails. Denies rashes, lumps, sores or changes in hair on face or nails. No changes in size or color of moles.

HEENT: head – Reports a headache with throbbing sensation right temporal region. Denies trauma, lightheadedness, or dizziness , eyes – Denies vision problems on a daily basis. Reports eyes bothering her when in light since her headache has started. Last eye exam one year ago with good report. No reports of any drainage, redness, or itching. No reports of double or blurred vision, spots, specks, or flashing lights. ears – Denies any ear pain or problems. Denies any drainage from ears. No tinnitus, vertigo, or infections. Hearing good, nose – Denies abnormal nasal conditions, no rhinorrhea, or nasal congestion.

throat –Denies any throat problems. Good report at last dental exam 1 year ago, no dental caries or signs of gingivitis. No history of cold sores or canker sores.

Thorax: Denies any swollen glands, lumps, or pain to neck. Lung disease, allergies, or asthma.

Breast: Denies pain, discomfort, or discharge from nipples.

Respiratory: No reports of coughing, congestion, wheezing, or shortness of breath. No history of lung disease, allergies, or asthma.

Cardiovascular: No reports of chest pain, pressure, or tightness. No complaints of tachycardia, palpitations, or cyanosis. Reports high cholesterol.

PVS: Denies extremity edema, coldness, leg cramps, varicose veins, or ulcers.

Gastrointestinal: Diabetic diet. Reports nausea for the last couple of hours since her headache has come on. Denies vomiting, diarrhea, or abdominal pain. Eats well. Bowel movements regular. Denies history of jaundice, gallbladder, or liver disease.

GU: Denies urinary frequency, hesitancy, incontinence, nocturia, flank pain, burning, or bleeding with urination. Denies history of urinary tract infections.

Genital: Regular menstrual cycles. Last cycle was 2 weeks ago. No cramping and very little blood noted with cycles. Denies any bleeding between periods or after intercourse. No reports of vaginal discharge, itching, sores, lumps, or sexually transmitted diseases. No concerns about HIV infection. State’s that she and her husband use condoms.

Musculoskeletal: Denies trauma or injury. No reports of swelling, stiffness, pain, or weakness to extremities.

Endocrine/Hematologic: Reports type II DM. Denies thyroid problems, heat/cold intolerance, weight loss, or weight gain. Denies any polydipsia, polyuria, or excessive sweating. Denies history of bleeding disorders or bruising easily. No history of blood transfusions.

Psychiatric: Denies trouble concentrating, nervousness, anxiety, panic attacks, mood changes, hearing voices, frequent unhappiness, or desire to harm self/others. No nightmares, memory loss, or excessive life stresses. No recent deaths in family or close friends.

Neurologic: Denies history of stroke, seizures, frequent/incapacitating headache, and tremors. No numbness or tingling in extremities.


General: White female, well kept, well-mannered. AAOX3, walks into examination room with slow movements, decreased facial mobility and a blunt expression noted. No changes in hair distribution on face.

Vital Signs: B/P-120/80, P-80, R-20, T-98.9, O2-99% Ht: 5’5”, Wt: 150 lbs., BMI: 25

Hair: WNL, thick and evenly distributed with no breakage, alopecia, dryness, or infestations

noted. Hair appears shiny and red in color. Eyebrows and eyelashes present and evenly


Skin: Warm, dry, supple, no bruises, rashes, or suspicious nevi to exposed skin.

Nails: Smooth and well manicured without clubbing or cyanosis. Capillary refill to finger pad is brisk.

Head/Neck: Normocephalic and atraumatic. Throbbing sensation located in the right temporal region. The pain does not travel to any other area. No bumps, bruises or lesions. Scalp pink and moist. No sinus tenderness, and no palpable lymph node enlargement or tenderness. Neck supple; thyroid isthmus palpable, lobes not felt. Trachea midline.

Eyes: Pupils 4mm constricting to 2mm, PERRLA, EOMI, negative strabismus and nystagmus, conjunctiva pink and moist. Sclera white. Eyes clear without drainage or redness.

Ears: Acuity good, no tenderness or abnormalities to tragus & pinna, ear canal without inflammation or cerumen noted bilaterally. TM pearly white and intact with no redness or bulging. Cone of light visible bilaterally (5 o’clock right, 7 o’clock left).

Nose: Turbinates intact and pink without edema, nares patent, no septal deviation, nasal flaring or discharge.

Throat/mouth: Membranes pink and moist. Uvula is midline, tonsils at pillars, no redness or exudates. Good dentition noted. No dental caries noted. Tongue midline.

Lungs: Respirations 20 breaths/min, breath sounds vesicular, no rhonchi, wheezes, crackles, or stridor present. Lungs resonant. Thorax is symmetric, and the diaphragms descend 4 cm bilaterally. No distress noted.

Heart: Scratching noise heard at lower left sternal border, coincident with systole. Apical pulse 80 bpm on auscultation. S1 and S2 regular rate and rhythm with no splitting, S1 best at apex, S2 best at base, with no S3 or S4. Carotid upstrokes brisk with no bruits. No JVD. PMI palpable at 5th ICS 7cm lateral to the midsternal line, discrete and tapping. No heaves, lifts, or thrills. No rubs, gallops, murmurs, or opening snaps.

Breasts: Symmetric and smooth without masses. Nipples without discharge.

Abdomen: Normoactive BS x 4 quadrants. No abdominal bruits. Soft, flat, and non-distended with no scars or striae. No abdominal tenderness to palpation. No palpable masses or hepatosplenomegaly. Kidneys not felt, no CVA tenderness.

Lymph Nodes: Head, neck, axilla, epitrochlear, and inguinal lymph nodes nonpalpable.

Extremities: Extremities are warm without edema. No varicosities or stasis. Calves are supple and non-tender. No femoral bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulse are all 2+ and symmetric. Full range of motion to all extremities. No deformities or enlarged joints.

Genitals: Deferred

Rectum/Anus: Deferred

Neurologic: Alert and oriented to person and place, and is cooperative. Answers questions and follows commands appropriately. Cranial nerves II-XII grossly intact. Slow movement due to pain from headache. Maintains balance with eyes closed. Good, even strength and muscle tone. Reflexes are 2+ and symmetric with plantar reflexes. Rapid alternating movements intact. Pinprick, light touch, position, and vibration intact.


  1. Diagnosis- Migraine: (During a migraine, the temporal artery, an artery that lies outside the skull and just under the temple, enlarges or dilates. This enlargement stretches the nerves that are coiled around the temporal artery and causes them to release chemicals that can cause inflammation, pain, and even greater enlargement of the artery. As the artery grows larger, the pain becomes worse (McCance, 2010).)
  2. Differential Diagnoses:
  3. Cerebral Aneurysms
  4. Chronic Paroxysmal Hemicrania
  5. Cluster Headache
  6. Exertional Headache
  7. Space-Occupying lesion
  8. Cerebral Venous thrombus
  9. Dissection Syndromes
  10. Herpes Simplex Encephalitis
  11. Intracranial Hemorrhage
  12. Muscle Contraction Tension Headache
  13. Temporal/Giant Cell Arteritis
  14. Tolosa-Hunt Syndrome
  15. Viral Meningitis
  16. Stroke


  1. Educate Pt about Migraine diagnosis and its treatment.
  2. RAT: It is important to provide pt with an overview of what the problem is and how it can best be managed (Uphold, 2003).
  3. Refer pt to web sites.
  4. RAT: Web sites are helpful with providing pt with more options on how to manage migraines (Uphold, 2003).
  5. Create a formal management plan with patient.
  6. RAT: This will implement preventive and/or acute episodic therapy for migraines (Uphold, 2003).
  7. Encourage pt to keep a headache diary.
  8. RAT: The diary will help assist in identifying precipitating events and risk factors. The diary will also help in tracking progress of treatment approaches (Dunphy, 2011).
  9. Encourage pt to identify and avoid triggers.
  10. RAT: Identifying things that trigger a migraine will help the pt to Avoid those triggers that cause a migraine. This will help lessen the frequency of migraines (McCance, 2010).
  11. Determine if patient is a candidate for preventive therapy for migraine headaches.
  12. RAT: This should be instituted if occurrence of migraine is 3-4 days per month or more. If migraines only occur 1-2 days per month, preventive therapy is not needed. If the recurrent migraines interfere with daily functioning despite treatment for acute attacks then preventive therapy should be considered.
  13. Discuss Nonpharmacologic therapies for the prevention of migraines.
  14. RAT: These therapies may be best suited for patients who have a poor tolerance of, or poor response to drug therapy, who have contraindications to drug therapy, who have a past history or excessive use of analgesics. Examples of nonpharmacologic therapies are relaxation training and cognitive-behavioral therapy (Uphold, 2003).
  15. Educate pt on the 2 classes of drug treatment for migraines.
  16. RAT: Help pt to distinguish between the two classes and will be able to help decide which class would benefit her.

1.) Drugs that can be taken daily whether or not headache is present to reduce the severity of attack (called preventive therapy). Start therapy at the lowest effective dose and increase it slowly until benefits are achieved. Inform pt that the medication must be given an adequate trial and it could take 2-3 months to achieve clinical benefit. Timolol 5 mg by mouth twice day (Uphold, 2003).

2.) There are also drugs that are taken to treat attacks as they arise. Efficacy of acute treatment is determined by correct choice of medication as well as the timing of intervention. Early intervention at the outset of the headache (when pain is mild) can abort headache in most cases within 2-4 hours with lower headache occurrence. Zomig 1.25-2.5 mg by mouth initially; may repeat after 2 hours , max 10 mg day (Uphold, 2003).

  1. Review and discuss the goals of long-term migraine treatment, both nonpharmacologic and pharmacologic.
  2. RAT: Setting goals will reduce attack frequency, severity, and patient disability. It will reduce patient reliance on poorly tolerated or ineffective medications and will also improve quality of life (Uphold, 2003).
  3. Antiemetic: Zofran 4 mg by mouth or dissolvable tablet placed under tongue every 4-6 hours as needed for nausea/vomiting.
  4. RAT: Should not restrict to pts who are vomiting/nauseated because this Is a very disabling symptom with migraines. If vomiting pt has choice of placing a dissolvable pill under tongue rather than a pill to swallow (Uphold, 2003).
  5. Follow up appointment.
  6. RAT: A follow up appointment will give pt time to start a headache diary and then can bring in to next appointment to see if any of the therapies that were discussed and started helped. Will give her time to monitor the frequency, severity, and response to therapies. Continue the headache diary and bring to the follow up that is scheduled every 2-4 weeks in first 3 months, then every 3-6 months. If the headaches are well controlled with preventive therapy after 3-6 months, consider tapering or discontinuing treatment (Uphold, 2003).
  7. Referral considerations.

RAT: If pt prefers nonpharmacologic treatments (ex. Behavioral treatment) or if pt does not respond to or fail treatments for moderate or severe migraine should be referred for expert management (Uphold, 2003).


Bickley, L. S. (2009). Bates’ Guide to Physical Examination and History Taking (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

McCance, K. L., & Huether, S. E. (2010). Pathophysiology: the biologic basis for disease in adults and children (6th ed.). Maryland Heights, MO: Mosby Elsevier.

Uphold, C. R., & Graham, M. V. (2003). Clinical Guidelines in Family Practice (4th ed.). Gainesville, FL: Barmarrae Books.