The 2026 Guide to Headache SOAP Note Examples for Healthcare Providers

If you've ever struggled to document headache visits in a way that captures red flags while efficiently managing common presentations, this guide is for you.

I've talked to countless primary care physicians, neurologists, and emergency medicine doctors who see headache patients daily and need documentation that differentiates benign from dangerous causes.

The reality is that headache documentation requires careful attention to red flags, neurological examination findings, and treatment response to avoid missing serious conditions.

Insurance companies want to see appropriate workup, clear reasoning for imaging decisions, and evidence-based treatment plans that justify medications and specialist referrals.

That's exactly why I built SOAP Notes Doctor to handle the documentation burden while you focus on identifying concerning features and providing relief.

In this article, I'll show you exactly how to write headache SOAP notes that meet clinical and insurance standards, with real examples you can adapt.

🧾 What SOAP Notes Really Are (And Why They Matter for Headache Evaluation)

SOAP notes might feel like bureaucratic busywork, but they serve a real purpose when evaluating headaches.

They were introduced in the 1960s by Dr. Lawrence Weed as part of the Problem-Oriented Medical Record (POMR).

His goal was straightforward: create a documentation system that anyone reviewing a chart could understand quickly and completely.

For headache evaluation specifically, SOAP notes are critical because they demonstrate:

• Systematic screening for red flags and dangerous secondary causes
• Appropriate neurological examination documentation
• Clinical reasoning for imaging versus conservative management
• Evidence-based treatment selection and medication trials
• Follow-up planning and reassessment strategy

SOAP stands for:

• S — Subjective: What the patient reports about headache onset, location, quality, severity, duration, frequency, triggers, associated symptoms, and previous treatments.
• O — Objective: Your clinical findings including vital signs, neurological examination, fundoscopic exam when indicated, and any imaging or lab results.
• A — Assessment: Your clinical diagnosis (migraine, tension-type, cluster, secondary headache), severity assessment, and red flag evaluation.
• P — Plan: Your treatment plan including acute medications, preventive therapy, lifestyle modifications, imaging if indicated, specialist referral, and follow-up timing.

This structure keeps your documentation organized, defensible, and insurance-friendly.

You're not just recording what happened—you're building a clinical narrative that shows you appropriately ruled out dangerous causes while providing effective treatment.

How You Can Approach Headache SOAP Notes

There's no single correct method for writing headache SOAP notes, but some approaches work better than others depending on your practice setting.

Here are two main approaches I've seen work well.

1. Traditional, Manual Documentation

This is the classic method: typing out each section after the visit. It works if you have strong clinical documentation skills and adequate time. The challenge is ensuring you consistently document all red flags, complete neurological exams, and treatment rationale, especially in busy primary care or ED settings.

2. SOAP Notes Doctor

You record your examination findings or dictate your observations, and the tool automatically structures everything into proper SOAP format. It maintains consistency, ensures you capture essential red flag screening, and saves time when documenting neurological exams and treatment plans.

How to Make Headache SOAP Notes Faster

One of the biggest complaints I hear from providers is how headache documentation can be time-consuming, especially when you need to document extensive history and complete neurological exams.

You've just finished evaluating a patient with a complex headache history, ruled out red flags, performed a detailed neuro exam, and now you need to document everything while your next patient is waiting.

The pressure is real: make them too brief and you risk missing documented red flag screening or neurological findings; make them too detailed and you've just added significant time to already busy days.

Here's what we built to solve this:

✅ Head to soapnotes.doctor
✅ Record your examination findings or dictate key observations
✅ Generate properly formatted SOAP notes instantly
✅ Ensure consistent red flag documentation

With soapnotes.doctor, you can record during or right after evaluation, add rough notes about specific findings, or even upload audio later. The system converts everything into proper SOAP notes automatically.

You still get the clinical accuracy and completeness needed for good documentation, but without manually typing every detail.

Maybe you noted specific findings?

"Bilateral throbbing headache, photophobia, nausea, no focal deficits, normal fundoscopy, POUND score 4/5, tried ibuprofen without relief, wants something stronger."

Use the tailorr feature to add them. Keep it raw and unpolished—soapnotes.doctor handles the rest.

Example 1: Acute Migraine Without Aura

Patient: 32-year-old female
Chief Complaint: "Severe headache with nausea"
Visit: Primary care urgent visit

S – Subjective:

Patient reports severe headache that started this morning upon waking, now 6 hours duration. Describes pain as throbbing, bilateral (mostly left temple and behind left eye), rated 8/10 severity. Associated with nausea (no vomiting), photophobia, and phonophobia. Reports similar headaches monthly for past 2 years, usually around menstrual cycle. Previous headaches respond to ibuprofen 600mg but she's out of medication. Denies fever, neck stiffness, vision changes, weakness, numbness, or confusion. No recent head trauma. Headaches typically last 6-24 hours if untreated. Triggers include stress, poor sleep, and menstruation. No aura symptoms. Family history positive for migraines in mother. Currently on oral contraceptive pills. Tried resting in dark room without relief.

O – Objective:

Vital Signs: BP 128/76, HR 82, Temp 98.4°F, RR 16
General: Alert, appears uncomfortable, prefers dim lighting
HEENT: Normocephalic, no scalp tenderness, pupils equal and reactive, extraocular movements intact, no papilledema on fundoscopy
Neurological: Cranial nerves II-XII intact, motor strength 5/5 all extremities, sensation intact, reflexes 2+ and symmetric, negative Romberg, normal gait, no meningismus
Neck: Supple, no rigidity, full range of motion

A – Assessment:

Acute migraine without aura. POUND criteria: 4/5 (Pulsatile, One-day duration, Unilateral, Nausea, Disabling intensity). No red flags present for secondary headache. Established pattern consistent with menstrual-related migraines. Inadequate acute treatment with OTC medications alone.

P – Plan:

Prescribed sumatriptan 100mg tablet, take at headache onset, may repeat once after 2 hours if needed (max 200mg/24 hours). Prescribed ondansetron 4mg ODT for nausea. Provided education on migraine triggers and importance of early treatment. Discussed keeping headache diary to track frequency, triggers, and treatment response. Recommended maintaining regular sleep schedule, adequate hydration, and stress management. If headaches occur more than 4 times monthly, consider preventive therapy—follow up to discuss options. Provided return precautions: sudden severe headache different from usual pattern, fever with headache, neurological symptoms, or headache not responding to treatment. Follow-up in 4 weeks or sooner if headaches increase in frequency or severity.

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Example 2: Tension-Type Headache, Chronic

Patient: 45-year-old male
Chief Complaint: "Daily headaches for the past month"
Visit: Primary care follow-up

S – Subjective:

Patient reports near-daily headaches for past 6 weeks, present 5-6 days per week. Describes pain as pressure-like, "band around head," bilateral, frontal and occipital. Rates severity 4-5/10. Headaches typically develop mid-afternoon, worse by end of workday. Denies nausea, vomiting, photophobia, or visual changes. No aura symptoms. Reports high stress at work with recent project deadline. Sits at computer 8-10 hours daily. Sleep quality poor, averaging 5-6 hours nightly. Taking ibuprofen 400mg daily, sometimes twice daily, with partial relief. Denies fever, neck stiffness, or neurological symptoms. No recent head trauma. No significant headache history prior to 6 weeks ago. Denies caffeine overuse.

O – Objective:

Vital Signs: BP 132/84, HR 74
General: Alert, well-appearing, no acute distress
HEENT: Normocephalic, mild tenderness to palpation over bilateral trapezius and occipital muscles, no scalp tenderness
Neurological: Cranial nerves intact, motor and sensory exam normal, reflexes symmetric, no focal deficits, normal gait
Musculoskeletal: Cervical spine full range of motion, mild paraspinal muscle tension

A – Assessment:

Chronic tension-type headache, likely related to occupational stress, poor ergonomics, and inadequate sleep. Medication overuse possible with daily NSAID use. No red flags for secondary headache. No indication for neuroimaging at this time given benign history and normal neurological exam.

P – Plan:

Discussed likely tension-type headache diagnosis and contributing factors including stress, posture, and sleep deprivation. Advised limiting ibuprofen to maximum 3 days per week to avoid medication overuse headache. Recommended acetaminophen 1000mg as needed for acute headaches, also limiting frequency. Prescribed amitriptyline 10mg at bedtime as preventive therapy, may increase to 25mg after 1 week if tolerated. Provided ergonomic counseling: adjust computer monitor height, take breaks every hour, neck stretching exercises. Emphasized importance of improving sleep hygiene with goal of 7-8 hours nightly. Recommended stress management techniques and consider counseling if work stress continues. Advised keeping headache diary to track frequency and identify patterns. Follow-up in 4 weeks to assess response to preventive therapy. Return sooner if headaches worsen, new symptoms develop, or if experiences sudden severe headache different from usual pattern.

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Example 3: First Episode Severe Headache, Requires Workup

Patient: 55-year-old female
Chief Complaint: "Worst headache of my life"
Visit: Emergency department

S – Subjective:

Patient reports sudden onset severe headache that started 3 hours ago while gardening. Describes headache as "worst I've ever had," 10/10 severity, generalized but worst in occipital region. Associated with nausea and one episode of vomiting. Denies loss of consciousness but felt briefly disoriented at onset. Denies fever, recent illness, head trauma, or neck pain. No previous history of severe headaches. Some mild photophobia. Denies vision changes, weakness, numbness, or difficulty speaking. No recent travel or sick contacts. Medical history includes hypertension (controlled on lisinopril) and hyperlipidemia. Family history negative for aneurysms but positive for stroke in father at age 68. Non-smoker, occasional alcohol use.

O – Objective:

Vital Signs: BP 168/94 (elevated from baseline 130/80), HR 96, Temp 98.6°F, RR 18, O2 sat 98% on room air
General: Alert, appears in significant discomfort, holding head
HEENT: Normocephalic, no scalp trauma, pupils equal and reactive (4mm to 2mm), no papilledema
Neck: Supple, no meningismus, no carotid bruits
Neurological: Alert and oriented x3, cranial nerves II-XII intact, motor strength 5/5 bilaterally, sensation intact, reflexes 2+ and symmetric, cerebellar testing normal, gait steady, negative Babinski
Cardiovascular: Regular rate and rhythm, no murmurs

A – Assessment:

Sudden onset severe headache, "thunderclap" presentation, concerning for subarachnoid hemorrhage versus other vascular cause. Red flags present: sudden onset, worst headache ever, peak intensity at onset, elevated blood pressure. Normal neurological exam does not rule out SAH. Requires urgent neuroimaging.

P – Plan:

Given sudden onset and severity, obtained urgent non-contrast head CT to evaluate for subarachnoid hemorrhage or other intracranial pathology. Placed IV access. Given ondansetron 4mg IV for nausea. Held pain medication pending imaging results. BP elevated, administered labetalol 10mg IV with reduction to 148/86. Neurology consulted. CT head result: No acute intracranial hemorrhage, no mass effect, no midline shift. Given negative CT but high suspicion, discussed lumbar puncture with patient to definitively rule out SAH. LP performed: Opening pressure 16 cm H2O (normal), clear and colorless CSF, cell count pending, xanthochromia negative. CSF results: WBC 2, RBC 0, protein and glucose normal. SAH ruled out. Diagnosis revised to severe primary headache, likely migraine variant versus thunderclap headache of benign etiology. Administered ketorolac 30mg IV and metoclopramide 10mg IV with significant improvement. Discharged with sumatriptan prescription and strict return precautions. Follow-up with primary care in 1 week and neurology in 2 weeks for further evaluation if headaches recur. Provided detailed discharge instructions on warning signs requiring immediate return: recurrent severe headache, neurological symptoms, fever, neck stiffness, or vision changes.

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Key Components Insurance Companies Look For in Headache SOAP Notes

When reviewing your headache documentation, insurance companies and utilization review specifically want to see:

1. Red Flag Screening

Document that you screened for dangerous causes: sudden onset, "worst headache ever," fever, neurological deficits, new headache in patient over 50, headache with exertion, immunosuppression.

2. Comprehensive Headache Characteristics

Location, quality, severity, duration, frequency, timing, triggers, associated symptoms. This supports diagnosis and treatment selection.

3. Neurological Examination

Document complete neuro exam including cranial nerves, motor, sensory, reflexes, gait, and fundoscopy when indicated. Normal exam is important for ruling out secondary causes.

4. Clinical Reasoning for Imaging

If ordering CT/MRI, document specific red flags or concerning features. If not ordering imaging, document why (benign features, normal exam, primary headache pattern).

5. Evidence-Based Treatment Selection

Document rationale for medication choices, previous treatment failures, contraindications considered, and step-wise approach to therapy.

6. Medication Overuse Assessment

Screen for and document frequency of acute headache medication use, especially when headaches are chronic.

Common Mistakes to Avoid

Vague Pain Description: Instead of "bad headache," document specific characteristics: "bilateral throbbing frontal headache, 7/10 severity, associated with photophobia."

Incomplete Red Flag Documentation: Always explicitly state presence or absence of red flags, don't leave them unaddressed.

Skipping Neurological Exam: Even if normal, document that you performed cranial nerve, motor, sensory, and reflex examination.

No Justification for Imaging Decisions: Document clinical reasoning whether you order imaging or choose conservative management.

Missing Medication History: Document what patient has already tried, doses used, and response to previous treatments.

Forgetting Medication Overuse Screening: Ask about and document frequency of all headache medication use including OTC drugs and caffeine.

Tips for Efficient Headache Documentation

Use Standard Review Templates: Create templates that prompt red flag screening and neurological exam components.

Document Normal Findings Efficiently: "Neurological examination normal including CN II-XII, motor/sensory/reflexes, gait, and cerebellar testing."

Standardize Headache Descriptors: Use consistent terminology (throbbing, pressure-like, stabbing) and scales (1-10, mild/moderate/severe).

Include POUND Score for Migraine: Document components (Pulsatile, One-day duration, Unilateral, Nausea, Disabling) to support diagnosis.

Reference Previous Notes: For established patients, note changes from baseline pattern or exam findings.

Final Thoughts

Headache SOAP notes don't need to be overwhelming.

They need to be thorough in screening for dangerous causes, yes, but they don't need to consume excessive time for routine presentations.

The key is having a system that consistently captures red flags, neurological findings, and treatment rationale without making documentation feel burdensome.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear documentation that shows appropriate clinical reasoning and safe patient care.

Your time is better spent evaluating patients and providing relief than typing repetitive documentation.

That's exactly why we built this tool.

Try it out, see how much time you save on headache documentation, and let me know what you think.

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Ready to simplify your headache documentation?
Visit soapnotes.doctor and get your first notes generated in minutes.