dizziness
face pain
fatigue
frequent urination
hallucinations
head pain
hyperactivity
insomnia
light sensitivity
loss of appetite
mood changes
nausea
neck pain
shoulder pain
smell sensitivity
sound sensitivity
stuffy nose
touch/skin sensitivity (allodynia)
visual changes
visual distortion
vomiting
yawning
other (describe): ______________________________________________
14. How long before your headaches start do these symptoms typically occur? _________________________________________________
15. If you have migraine with aura, describe your aura symptoms: _________________________________________________________
16. Circle the word(s) that best describe your typical headache pain:
aching
band-like
beating
boring
constant
drilling
dull
gripping
hurting
intermittent
painful
piercing
poking
pounding
pulsating
sharp
shooting
sore
stabbing
stake-like
steady
tender
throbbing
tight
viselike
17. Indicate the usual intensity of your headaches by circling a number on the pain scale:
| 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| | | | | |||||||||
| No pain | Most intense pain imaginable |
18. Circle other symptoms you get during a headache:
anxiety
appetite loss
back pain
constipation
depression
diarrhea
dizziness
face pain
fatigue
general pain
hallucinations
lethargy
light sensitivity
mood changes
nausea
neck pain
scalp pain
shoulder pain
sinus pain
smell sensitivity
soreness
sound sensitivity
tenderness
touch/skin sensitivity (allodynia)
visual changes
vomiting
other (describe): ____________________________________________
19. Do you wake up with headaches? yes _____ no _____
20. Circle any factors that seem to trigger your headaches:
Dietary
aged cheeses
alcohol / alcoholic beverages
artificial sweeteners
beans
beer
caffeine
chocolate
citrus fruits
dairy products
fatty foods
food sensitivity (list): ___________________________
hot dogs
irregular eating
lack of caffeine
lack of water
low blood sugar
luncheon meats
MSG
nitrates, nitrites
nuts
pickled foods
preservatives, chemical
additives
skipping meals
