Emergency Treatment Request and Information: 

Below, is information to assist you in treating my patient:

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for this severe Cluster Headache episode. As you know, Cluster Headache Disorder is a recurrent, episodic neurological disorder. Some episodes can require treatment beyond the medications the patient currently has at home. This patient is neither a substance abuser nor a "drug seeker," but may need narcotic medications to treat this episode.

Patient Information:                             Date of diagnosis: __________________
      
Current migraine preventive medication(s): ______________________________________
               
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Current migraine abortive and/or pain medication(s): ______________________________
        
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Suggested medications for this patient in an emergency situation:
        
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         __________________________________________________________________________

Thank you for treating my patient. It is often very difficult for Cluster Headache patients to receive adequate care offered with dignity and respect because of others who go to emergency departments and after-hours care facilities, feigning symptoms to obtain narcotics. I assure you such is not the case with this patient.
     

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Signature                                                                                            Date
        
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Address                                                                                              Office Phone
          

http://headaches.about.com
headaches.guide@about.com