Treating physician finds the condition stable on current regimen and no changes recommended Yes Acceptable s of Migraine or Headache Classic Common Migraine Chronic Tension hea ID: 850111
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1 CACI Migraine and Chronic HeadacheWorksh
CACI Migraine and Chronic HeadacheWorksheet(Updated 04/29/2015)The Examiner must review a current status report by the treating physician and any supporting documents to determine the applicant’s eligibility for certification. If the applicant meetsALL the acceptable certificationcriterialistedbelow, the Examiner can issue. Applicants for firstor secondclass must provide this information annually; applicants for thirdclass must provide the information with each required exam. Treating physician finds the condition stable on current regimen and no changes recommended [ ] Yes Acceptable s of Migraine or Headache [ ] Classic /Common Migraine , Chronic Tension headache , Cluster headache NOT acceptableOcular migraine, complicated migraine [ ] No more than one episode per month Symptom s [ ] Only m ild symptoms cont rolled with m edication (s) listed below . [ ] NOTacceptableneurological or TIAtype symptomsvertigo syncope ; and/ or mental status change Medications Preventive [ ] None ; or d aily calciu m channel blockers or beta blockers only for prophylaxis without side effects Medications - Abortive ; warn airman: 24 hour noflyTriptans 36 hour nofly etoclopramide(Reglan); 96 hour nofly promethazine(Phenergan) N OT acceptable : Injectable medications and narcotics AME MUST NOTE inBlock 60 of the following:ng:CACI qualified migraine and chronic headaches. [ ] Not CACI qualified migraine and chronic headaches. Issued per valid SI/AASI. (Submit upporting documents.)[ ] NOT CACI qualified migraine and chronic headaches. I have deferred. (Submit supporting documents.)