HEADACHE AFTER METHYLENE BLUE: SYMPTOM-HISTORY WORKSHEET Complete for a clinician or pharmacist. This records an episode; it does not diagnose its cause or recommend treatment. Do not delay urgent care to complete it. Do not repeat an exposure to test whether pain returns. Emergency help: sudden extremely severe headache; new weakness or trouble speaking; collapse; or headache with difficulty breathing and blue/grey lips. After exposure, confusion or agitation with fever and muscle stiffness, tremor, or jerking also needs urgent medical assessment. Name or initials: ______________________ Completed on: ______________ 1. USUAL HEADACHE PATTERN Previous migraine/headache diagnosis, if any: _________________________ Usual headache days per month: _______________________________________ Usual location, duration, and associated symptoms: ____________________ _____________________________________________________________________ Usual aura, if diagnosed: ____________________________________________ What was different this time? ________________________________________ _____________________________________________________________________ 2. EXACT EXPOSURE Product name and manufacturer: _______________________________________ Lot/batch and expiry: ________________________________________________ Label concentration and units, copied exactly: _______________________ Amount used and units (write UNKNOWN if uncertain): __________________ Route (swallowed, injected, skin contact, other): _____________________ Date/time of each exposure relevant to this episode: _________________ _____________________________________________________________________ Reason for use; who recommended or administered it: ___________________ _____________________________________________________________________ Other ingredients shown on label: ____________________________________ Container or label photograph available? _____________________________ 3. THIS EPISODE Date/time pain started: ___________ Time to worst pain: _______________ Location and character: ______________________________________________ Worst severity 0-10 (0 none; 10 worst imaginable): _____________________ End time or still ongoing: ___________________________________________ Activities interrupted: ______________________________________________ Visual, sensory, or speech symptoms and their timing/duration: ________ _____________________________________________________________________ Other symptoms (for example nausea, fever, sweating, tremor, breathing changes, skin/lip color change, confusion), with timing: ______________ _____________________________________________________________________ What happened next, including any medical assessment: ________________ _____________________________________________________________________ 4. MEDICINES AND OTHER CONTEXT List prescriptions, nonprescription medicines, supplements, and recent changes. Include headache prevention, acute treatment, antidepressants, pain medicines, and cough medicines. Use another page if needed. Name Amount/units Last taken date/time ______________________ ___________________ _______________________ ______________________ ___________________ _______________________ ______________________ ___________________ _______________________ ______________________ ___________________ _______________________ Days per month using acute headache medicines: _______________________ Recent illness, sleep/caffeine changes, missed meals, or other possible contributors: ________________________________________________________ Relevant history, including G6PD deficiency if known: _________________ _____________________________________________________________________ 5. QUESTIONS FOR THE APPOINTMENT Does this resemble my established headache disorder or require a different assessment? ________________________________________________ Could the exposure or a medicine interaction contribute? ______________ What plan should I follow if symptoms recur? _________________________ Agreed follow-up and contact details: ________________________________ Prepared for the Blupreme article "Methylene blue and migraine: treatment claims versus headaches after use", 12 September 2026. History fields informed by NICE CG150 headache assessment guidance: https://www.nice.org.uk/guidance/cg150/chapter/recommendations Emergency headache features: https://www.nhs.uk/symptoms/headaches/ Methylene blue adverse reactions and interaction symptoms: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4f6848e5-35ed-4046-b13c-3032b5ba3232