Paediatric Neurology Regional Tertiary Headache Clinic Referral Form (Page 2 of 3) in pdf

Do you think this referral is:

Urgent

Semi-Urgent

Non Urgent

Are you concerned these are secondary headaches?

⃝ YES

⃝ NO

Have you spoken with Paediatric Neurology?

⃝ YES

⃝ NO

If Yes, when and with whom? _____________________________________________________________________

How long has the child had headaches?

________________________________________________________

How often is the child seen in your office for headache management? ___________________________________

What date was the child last seen by you? ________________________________________________________

In the past three months have the headaches become worse?

⃝ YES

⃝ NO

If yes, how so:

⃝ Frequency

⃝ Severity

⃝ Duration

Has the child kept a headache diary?

⃝ YES For how long? ___________

⃝ NO

Does the child have more than 15 headaches per month?

⃝ Yes

⃝ No

From your perspective are these headaches:

⃝ Acute

⃝ Acute recurrent

⃝ Chronic Progressive

⃝ Chronic non progressive

Note: Please see suggestions below for Chronic Non Progressive headaches, if they have not been tried.



Symptomatic Treatment with Robust doses of Ibuprofen (10mg/kg. Max 600 mg/dose) or Acetaminophen (20

mg/kg Max 1 Gm/dose) Not to be used >8 days/month



Prophylactic Treatment for headache occurring >10 days/month with either Amitriptyline, Nortriptyline,

Flunarizine, Propranolol, Topiramate, or Valproic Acid for at least three months. We suggest a 3 month trial of at

least two separate medications without success before making a referral to our program.

Neurological Exam:

⃝ Normal

⃝ Abnormal

Abnormal Findings: _____________________________________________________________________________

Fundoscopy exam

⃝ Normal

⃝ Abnormal

Abnormal Findings: _____________________________________________________________________________

Diagnostic Imaging

⃝ Yes

⃝ No

Date/Results: ________________________________________

Reports Attached

⃝ Yes

⃝ No

If NO, state why not ________________________________________________________

Are there psycho/emotional co-morbidities?

⃝Depression

⃝ Anxiety

⃝ Other ______________________________

Are the parents worried about these headaches?

⃝ Yes

⃝ No

What type of reassurance has been provided? ____________________________________________________

Regional Paediatric Tertiary Headache Clinic, Children’s Hospital, London Health Sciences Centre

Room B1-169A, North Tower, Victoria Hospital, 800 Commissioner’s Rd E, London, ON, N6A 5W9

Phone: 519 685-8332 Ext 2

Fax: 519 685-8350

Paediatric Neurology Regional Tertiary Headache Clinic Referral Form Page 2

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