Headache Questionnaire
DIRECTIONS: Please answer all questions to the best of your ability
1. What is your main headache-related problem: (check only one) __a. Headaches
__b. Headaches and neck pain __c. Face pain
__d. Neck pain
2. When in your life did you first have any kind of headache: __a. Childhood __d. 40’s
__ b.Teenager __e. 50 and over
__c. 20’s – 30’s Age of onset if known_______
3. Have you previously been diagnosed with: a. Migraine 1. __YES 2. __NO
b. Tension headache 1.__YES 2.__ NO
c. Sinus headache 1.__YES 2.__NO
d. Cluster headache 1.__YES 2.__NO
e. Headache from neck 1.__YES 2.__NO
f. Trigeminal neuralgia 1.__YES 2.__NO
g. Other:_______________________
4. Where is your pain located: (check all that apply)
a. HEAD: __ 1.left side __5. top of the head __ 2.right side __6. back of the head __ 3.forehead __7. all over
Where is your pain located (cont.):
b. NECK: __1. left neck __2. right neck __3. both sides __4. none
5.What does your pain feel like: (check all that apply)
__1. steady __6. tightness/band-like __2. dull __7. exploding
__3. aching __8. Sharp/stabbing __4. throbbing __9. Intense
__5. pressure-like
Describe your pain in your own words: _______________ _______________________________________________
6.In the past 3 months are your headaches becoming: (check all that apply)
__1.stronger/more severe __2.longer lasting
__3.more frequent __4.about the same __5.not as bad
7.How many TOTAL headache days have you averaged over the past 3 months: (pick one best answer)
__1. 0-4 __2. 5-9 __3. 10-14 __4. 15-20 __5. 21-30.
9. Does rest or sleep relieve or stop your headache: YES NO
10. Do any of the following physical activities trigger a headache, head pain or face pain: (check all that apply)
__1.coughing __8. Standing up __2.sneezing __9. Laying down __3.bending over __10. chewing __4.straining __11. swallowing __5.lifting __12. talking __6.exercise __13. laughing
__7.sexual activity __14. Touching the face
11. Do any of the following seem to trigger your headache: (Check all
that apply)
__1. stress __9. loud noise
__2. alcohol __10. change in the weather __3. odors(e.g. perfume, smoke) __11. heat/hot weather __4. hunger/not eating __12. cold/ice cream __5. too much sleep __13. Allergies __6. too little sleep __14. Sinuses
__7. fatigue __15. School/exams __8. bright light/sunshine
16. Foods (name)________________________________________ 17. Medications (name)___________________________________
12. What makes the pain BETTER (check all that apply) __1. rest __5. laying down __2. darkness __6. standing up
__3. quiet __7. taking medication
13. Which of the following are likely to occur with your headache: (check
all that apply)
__1. sensitivity to light __10. blurred vision __2. sensitivity to loud noise __11. numbness __3. sensitivity to odors __12. weakness __4. nausea __13. one eye tears __5. nausea and vomiting __14. both eyes tear __6. diarrhea __15. nose runs
__7. feel lightheaded or dizzy __16. head is stuffed up __8. neck is stiff/sore __17. can’t go to work/school __9. feel confused/disoriented __18. must leave work/school
14. FEMALE ONLY
A. Do your headaches occur or get worse around the time of your period(menses) ?
__1. YES __2. NO
B. Have you taken Birth Control Pills or replacement estrogen for menopause or after hysterectomy ?
__1. YES __2. NO
If YES, did headaches get worse , better or no change ? __1. WORSE __2. BETTER __3. NO CHANGE
15. Do any of the following occur just before your headache starts: (check
all that apply)
__1. blurred vision __7. numbness __2. black spots __8. tingling __3. wavy lines __9. weakness
__4. flashes or sparkling lights __10. trouble speaking __5. bright lines and/or colors __11. dizziness/vertigo
__6. zig zag lines __12. double vision
16. Do you have warnings that start hours or days before you get a headache: (check all that apply)
__1. dizziness __5. food cravings __2. mood changes __6. sleepiness __3. irritability __7. yawning
Other_________________________________________________
17. Did your headache, head pain or neck pain start after :
__Accident/ injury Date___________ __Illness/ infection Date___________ __Traumatic life event Date___________
18. Who else in your family has had HEADACHE OF ANY KIND: (check
all that apply)
__1. mother __5. children __2. father __6. grandmother __3. sister __7. grandfather __4. your children __8. uncle/aunt
19. Have you been to an Emergency Room or Urgent Care Clinic for headache/head pain treatment:
__1. YES __2. NO
If yes, how many times in the past year:
__1.none __2.one time
__3.2-3 times
20. Which of the following treatments have you tried in the past or are using currently: (check all that apply)
__1. relaxation/biofeedback __11. exercise __2. massage __12. dieting __3. physical therapy __13. meditation __4. chiropractic/manipulation __14. yoga __5. osteopathic __15. hypnosis
__6. naturopathic __16. trigger point injections __7. acupuncture __17. nerve blocks
__8. psychotherapy __18. change work/school routine __9. counseling __19. surgical procedures
__10. TMJ treatment __20. pain management program
21. Have you experienced any of the following in the PAST: (check all that
apply)
__1. unhappy childhood
__2. abuse (emotional, verbal, physical, sexual) __3. separation or divorce
__4. depression __5. job loss
__6. prolonged illness/disability
22. Do you CURRENTLY have any of the following stresses: (check all
that apply)
__1. spouse/partner relationship problems __2. family relationship problems
__3. separation/divorce __4. job loss/unemployment __5. financial problems __6. legal problems __7. abuse
__8. trouble at work or school __9. loneliness/isolation
23. Have you had any of the following tests for your headache/head pain problem: (check all that apply)
__1. eye exam __6. blood tests __2. MRI head scan(where:____________) __7. allergy tests __3. MRI neck scan(where:____________) __8. spinal tap
__4. CT head scan __9. sinus exam or x-rays __5. psychological testing __10. dental evaluation
24. When you have pain which of these medications have you tried: (check
all that apply)
A. Over the Counter B. Prescription Migraine C. Prescription Pain __1. aspirin __1. sumatriptan(Imitrex) __1.Vicodin/Norco __2. ibuprofen(Advil) __2. Maxalt __2. oxycodone/Percocet __3. naproxen(Aleve) __3. Zomig __3. hydromorphone __4. Excedrin/Anacin __4. Relpax (Dilaudid) __5. acetaminophen __5. Frova __4. morphine
(Tylenol) __6. Axert __5. Fiorinal/Fioricet __6. sinus medicine __7. Naratriptan(Amerge)__6. Darvon/Darvocet __7. allergy medicine __8. DHE-45 __7. Tylenol with codeine __8. Canadian pain __9. indomethacin __8. Demerol
pills 2-2-2’s __10. Metoclopramide __9. Actiq lollipops __11. Midrin __10. tizanidine __12. Cafergot __11. oxygen
__13. Migranal
25. What medications have you tried to PREVENT headaches: (check all
that apply)
__1. amitriptyline/nortriptyline __11. Botox __2. propranolol/beta blockers __12. Effexor __3. topiramate(Topamax) __13. Cymbalta
__4. zonisamide(Zonegran) __14. carbamazepine(Tegretol) __5. valproic acid(Depakote) __15. oxcarbazepine(Trileptal) __6. verapamil/calcium blockers __16. magnesium or Vit B2 __7. gabapentin(Neurontin) __17. Namenda __8. cyproheptadine __18. feverfew __9. Lyrica __19. butterbur(Petadolex) __10. levetiracetam(Keppra) Other:___________________________________________________
