|
Type of Request:
|
Chronic Migraine Diagnosis:
|
|
Other Dx:
|
Procedure Code(s):
|
|
Initial History of Headaches -
|
Duration of Illness (months):
|
|
# of Headache days per month at Baseline:
|
How many hours do headaches last per day?
|
|
Pain Intensity:
|
Symptoms occurring with headache pain:
• • •
|
|
Disability due to headache/migraine:
• • •
|
# of ER visits due to headache/migraine per month:
|
|
Documenting Treatment Outcomes: Re-treatment Criteria
|
# of Headache days per month post-treatment:
|
|
Reduction from Baseline:
|
|
|
Pain Intensity:
|
Symptoms occurring with headache pain:
• • •
|
|
Disability due to headache/migraine (post-treatment):
• • •
|
Reduction in # of ER visits (post-treatments):
|
|
|
|
|
Prophylactic Drug Class Prescribed (2 meds from 2 different classes):
|
Drug Name:
|
|
Dose:
|
Duration:
|
|
Outcome:
|
|
|
Drug Name:
|
Dose:
|
|
Duration:
|
Outcome:
|
|
Drug Name:
|
Dose:
|
|
Duration:
|
Outcome:
|
|
Drug Name:
|
Dose:
|
|
Duration:
|
Outcome:
|
|
|
|
|
Acute/Abortive Drug Class Prescribed (2 meds from 2 different classes):
|
Drug Name:
|
|
Dose:
|
Duration:
|
|
Outcome:
|
Drug Name:
|
|
Dose:
|
Duration:
|
|
Outcome:
|
|
