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Headache-Helper


This questionnaire is not designed to, nor should it be used as a screening test for consequences to trauma, brain tumor, or mass lesions.

The following questions are directed at identifying the headache type(s) you are suffering from. Please be sure to answer all questions that apply to your headache condition. Some questions may appear to be repetitive. They are not. They pertain to different headache types. And some apply to females only. When answering questions please keep the section heading in mind and answer the question as it pertains to that section.


* = Required information

First Name :  *
Last Name :  *
Zip Code :  *
Tel No :  * digits only; no "( ),-";
email  (for email copy of report)
Referring doctor/health care facility*

Sex Male Female
Present Age
Age when you first started getting headaches
As a child or adolescent did you have severe occasional hedache? Yes No
If yes, were they:

Pain Descriptors - Do you now, or have you ever had the following headache pains :
At least 5 attacks of throbbing or pulsating headache lasting 4 to 72 hours (untreated or unsuccessfully treated) Yes No
At least 10 attacks of pressing or tightening pain (non-pulsatile), usually affecting both sides of the head, that can last from 30 minutes to 7 days Yes No
Sharp, jabbing brief head or face pain that comes and goes quickly Yes No
Medical History: The following questions relate to your past medical history
Has a physician ever diagnosed you with any of the following conditions? (check all that apply) high blood pressure diabetes
asthma or lung disease heart disease
arthritis hay fever or environmental allergies
epilepsy or seizures cancer
stroke or TIA (transient ischemic attack) glaucoma
obstructive sleep apnea sinusitis
TMJ (temporomandibular joint disorder) giant cell/granulomatous astrixis
cluster migraine
tension-muscle contraction trigeminal neuralgia
occipital neuralgia a neurologic condition resulting in a brain or skull operation
Have you been diagnosed or treated as having psychological problems? Yes No
If yes, which ones?(check all that apply) anxiety obsessive compulsive
panic attacks manic depression(bipolar)
attention deficit alcoholism
post traumatic stress disorder depression
The following questions relate to any previous headache evaluation
Have you been previously examined by a medical doctor or neurologist specifically for headache? Yes No/don't know
had a CT scan of the brain had a MRI scan of the brain
had a EEG (electroencephologram)
Have you visited a medical doctor for treatment of your headache?
Family History - Has anyone in your family (blood relatives) had ...
Headaches? Yes No
If yes, which type?(check all that apply) migraine-type unknown common migraine
classical migraine (aura) cluster
tension muscle contraction
A stroke or TIA (trans ischemic attack) Yes No
epilepsy Yes No
glaucoma Yes No
emotional or psychological problems Yes No
If yes to emotional or psychological, which ones?(check all that apply) anxiety obsessive compulsive
panic attacks manic depression(bipolar)
attention deficit alcoholism
depression post traumatic stress disorder
Medication History
Have you taken or are you presently taking any of the following class of medicines for headache?
hormonal contraceptives hormonal replacement therapy
anticonvulsants? (check all that apply) depakote tegretol
dilantin topamax
neurontin
other medications antidepressants calcium channel blockers
MAO inhibitors beta blockers
non steroidal anti-inflamatories triptans
other prescription medications analgesic/pain relievers including triptans
If you have a bad headache, how many painkillers might you use in a single day?
On average, how many painkillers do you take each day?
Over the course of a month how many painkillers might you use?
Social History
Marital status (select one)
What type of work do you do? (select one)
Does your work involve lifting or repetitive activity? Yes No
Does your work involve prolonged sitting? Yes No
Does your work involve using a keyboard or similar machine operation? Yes No
What is your level of education? (select one)
Do you smoke? Yes No
Do you drink alcolol? Yes No
caffeine use (coffee,tea,colas)(check all that apply) 0-3 cups coffee per day 4 or more cups of coffee per day
4 or more caffeine sodas per day 3 or more caffeine containing pain relievers per day
Medical Review of Systems
The following question relate to symptoms of medical conditions that you experience
trouble sleeping
muscle pains
pain in sinuses
pain localized to one area of the face
local area of facial tenderness
nightime urination,two times or more
nightime leg cramps
pain on opening your mouth widely
ringing in your ears
jaw locks in open position when opening mouth widely
sloshing feeling in your sinuses when you change position from lying to sitting or standing
green or yellow discharge when blowing your nose
treated for sinusitus
nasal congestion/stuffy nose
post nasal drip
temporary vision loss in one eye
temporary hearing loss
chills or night sweats
jaw fatique/or pain with prolonged chewing or talking
periods of confusion
temporary facial numbness
epileptic seizure
severe pain in your temple-sensitive to pressure
temporary numbness in your face and arm at the same time
temporary weakness on one side of your body
temporary lack of coordination in an arm or leg
temporary staggering or disequilbrium when walking
temporary double vision
temporary slurred speech
temporary drooping of one side of your face
black outs or syncope(feinting)
have others seen you have periods of "glassy eyed" staring or "spaceouts"
eye pain
see halos around bright lights
squinting to see well
eye fatigue after reading fine print
need glasses or magnifying lens to seee fine print
smoke cigarettes
drink alcolol
morning stiff neck
The following questions are for FEMALES only ...
Are you, or do you experience the following
pregnant? Yes No
postmenopausal? Yes No
headaches occur only at the time of your menstrual period? Yes No
headaches occur at any time but are usually worse at the time of your menstrual period? Yes No
were you ever pregnant?(skip next question if 'no') Yes No
if yes; was your pregnancy associated with :
poor posture? Yes No
heavy breasts? Yes No
neck pain or stiffness? Yes No
pain between the shoulder blades? Yes No
aching shoulders? Yes No
headaches improve by lying down? Yes No
worsening of pain when bending forward? Yes No
Stress and Sleep Factors - Do you experience any of the following
(check all that apply) extreme stress dislike your job
health problems money problems
a lot on your mind excessive worry
excessive anxiety or apprehension mind goes blank
tense(feeling keyed up,on edge) sad or blue
thoughts of death or suicide increased muscle tension
feeling overwhelmed, helpless moody or irritable
poor self image or bad feelings about yourself low energy level
easily fatigued loss of interest in things you used to enjoy
change in appetite change in sex drive
intrusive,unwanted thought or worries restless-toss and turn
mind runs continuously when trying to sleep irritability if things are out of place,not right
repetitive activities-handwashing, ordering, checking,etc
Are you in a difficult situation-moving,job change, divorce? Yes No
Do you have any of the following symptoms of disturbed sleep?
insomnia
sleepy during the day
trouble with memory or concentration
drowsy while reading or driving
forget what you read
other people tell you that you snore
wake up choking or gasping
restless, uncomfortable legs when trying to sleep
other people tell you that you stop breathing while sleeping
frequent muscle aches and pains
restless uncomfortable legs when trying to sleep? Yes No
numbness, tingling, crawling feeling in legs when trying to sleep? Yes No
urge to move or stretch if inactive or sitting to long (bus, desk, or airplane)? Yes No
unpleasant and uncomfortable leg sensations relieved by moving or stretching? Yes No
unpleasant, uncomfortable sensations worse at night or only at night? Yes No
constant tapping of feet or squirming when sitting? Yes No
Throbbing or Pulsatile Headaches
If you experience throbbing or pulsatile headaches, please complete the following section.
On average how long can your throbbing headache last if not treated?
How often do you get throbbing headaches?
If daily or almost daily, has the headache been present one month or more? Yes No
If yes to the above, over the last three months or more have you had increasingly frequent pulsating headaches that are less severe? Yes No
How many times per month does throbbing headache interfere with family activites or daily routine?
How many times per month does throbbing headache reduce work productivity by half or more?
How many times per month does throbbing headache cause you to miss work?
How many times per month does throbbing headache cause you to miss family, social or leisure activities?
On a scale of 1-10,rate how severe your worst throbbing headaches are (4=bothersome, but you can still do daily activities;7=so severe you have to stop what you are doing;10=the worst you can imagine, have to go to ER for help)?
How many times in the last three months have you called your doctor and/or gone to the ER because of throbbing headache?
The following questions pertain to people who suffer from throbbing/pulsatile headaches.
Does your headache pain have the following characteristics?
Triggered by a specific substance.
msg Yes No
nitrites(preservatives) Yes No
chocolate Yes No
alcohol(red wine especially) Yes No
estrogen(birth contol pills) Yes No
hormone replacement therapy Yes No
Is the pain generally pulsating? Yes No
Unilateral(one sided)? Yes No
Aggravated by routine physical activity? Yes No
Usually moderate or severe in intensity? Yes No
During the headache do you experience:
Nausea and/or vomiting? Yes No
Bright light hurts your eyes (sensitivity to bright light)? Yes No
Loud noises are intolerable. Yes No
Smells seem bad or bothersome (hypersensitivity to smells). Yes No
Do your throbbing/pulsatile headaches have any of the following characteristics?
Frequent temporal association with menstrual cycle (females only)? Yes No
Occur during sleep or upon awakening? Yes No
Relieved by sleep? Yes No
Cause a sick feeling all over (malaise)? Yes No
Cause a a desire to lie down in a dark,quiet place? Yes No
Interfere with clear, crisp thinking-feeling foggy? Yes No
Occur with dizziness or vertigo? Yes No
Headache pain can change from one side of the head to the other side with different attacks? Yes No
Are your throbbing/pulsatile headaches affected or aggravated by?
sexual intercourse Yes No
by strenuous physical exertion Yes No
missing a meal Yes No
lack of sleep,too much sleep,fatique, post stress(weekends,vacations) Yes No
glare,flashing lights,fluorescent lighting,odors Yes No
weather changes, especially low barometric pressure Yes No
alcohol Yes No
red wine Yes No
At any time in your life did you experience car sickness or motion sickness? Yes No
Recurrent attacks of vertigo or stomach pain? Yes No
Before throbbing/pulsatile headaches come on do you experience:
irritability Yes No
elation Yes No
physical hyperactivity Yes No
yawning Yes No
food craving Yes No
increased bowel or bladder activity Yes No
mental or physical slowing Yes No
poor concentration Yes No
word finding difficulty Yes No
weakness or fatigue Yes No
poor appetite,bloating,constipation Yes No
aura-fully reversible neurological symptom(such as seeing wavy or zigag lines,double vision) present on at least two occasions that occur at the onset of your headache or up to sixty minutes before the headache starts Yes No
If yes, which ones? (check all that apply) blurring or loss of vision numbness or tingling in face,arm or one side of the body
double vision, clumsiness,staggering gait,slurred words trouble talking or finding words
weakness on one side of your body more than one aura occurring in succession
do you have severe throbbing/pulsatile headaches that occur at the same time every day or every night for days or weeks at a time? Yes No
If yes, which ones? (check all that apply) do they usually go away after 3 hours or less? are they unilateral(one sided)?
can they awaken you from sleep? do they occur in the eye, behing the eye or in the temple?
if yes, are they associated with (check all that apply): red bloodshot eyes swelling of half the face or eyelid
nasal stuffiness or runny nose cause you to pace around/restless
tearing(watering) of the eye
do you have daily or almost daily throbbing headaches greater than 15 times per month that have been present for a month or longer? Yes No
over the last three months or more, have you had increasingly frequent pulsating headaches that are less severe or briefer? Yes No
Pressing/Tightening Headaches
If you experience pressing or tightening headaches(nonpulsatile), please complete the following section.
On average how long can your pressing or tightening headache last if not treated?
How often do you get pressing or tightening headache pain(select only one)?
If daily or almost daily, has the headache been present for 6 months or more? Yes No
If "yes" to the above, have your headaches gradually increased in severity and duration over a period of 3 months or more? Yes No
How many times per month does pressing or tightening headache interfere with family activities or daily routine?
How many times per month does pressing or tightening headache reduce work productivity by half or more?
How many times per month does pressing or tightening headache cause you to miss work?
How many times per month does pressing or tightening headache cause you to miss social or leisure activity?
On a scale of 1-10,rate how severe your worst pressing or tightening headaches are (4=bothersome, but you can still do daily activities;7=so severe you have to stop what you are doing;10=the worst you can imagine, have to go to ER for help)?
How many times in the last three months have you called your doctor and/or gone to the ER because of pressing or tightening headache?
The following questions pertain to people who suffer from pressing or tightening headache pain.
Does your headache pain have the following characteristics?
constant Yes No
dull,achy,pressing,tightening Yes No
bilateral-hurts all over Yes No
not aggravated by routine physical acitivity Yes No
not associated with nausea and vomiting Yes No
sensitivity to noise Yes No
sensitivity to light Yes No
can last 30 minutes to 7 days Yes No
mild to moderate severity Yes No
spreads out and tightens like a band Yes No
hurts worse in the morning on awakening Yes No
lessens in the afternoon or evening Yes No
Is your pressing or tightening headache pain associated with(check all that apply): musculuskelital pain pain or tenderness to touch at the base of your skull
morning stiff neck shoulder pain and/or pain between your shoulder blades
aggravated by coughing,sneezing,straining aggravated by bending or twisting your neck and shoulders
aggravated by using a high pillow aggravated by carrying a heavy handbag,luggage or picking up a child
certain points on the scalp,face or neck are tender to the touch
Nighttime sleep habits
How many pillows do you use under your head whwn sleeping?
Do you ever fall asleep on a couch or a recliner? Yes No
Do you get up from sleep to urinate more than once? Yes No
Do you get cramps in your legs when sleeping? Yes No
If you experience Sharp, Jabbing pain please complete the following section.
Is the headache triggered by touching,bending or twisting, or similar physical activity? Yes No
How long have you had sharp, jabbing pain?
How long does it take the sharp, jabbing pain to reach a maximum?
How many sharp, jabbing pains can occur in a day?
How often do sharp,jabbing pains occur?
How many times per month does sharp, jabbing pain interfere with family activities or daily routine?
How many times per month does sharp, jabbing pain reduce work productivity by half or more?
How many times per month does sharp, jabbing pain cause you to miss work?
How many times per month does sharp, jabbing pain cause you to miss family social or leisure activities?
On a scale of 1 - 10, rate how severe your worst headaches are: (4 = bothersome, but you can still do daily activities; 7 = so severe you have to stop what you are doing; 10 = the worst you can imagine.. go to the ER for help)
How many times in the last three months have you gone to the ER or called your doctor because of sharp,jabbing headaches?
If you experience sharp, jabbing pain please complete the following section.
Does your face or head pain have the following characteristics?
Is the pain sudden and without warning? Yes No
Are there places or points you touch that trigger the pain? Yes No
if yes to the above question,check all that apply: face scalp
base of skull when chewing or swallowing
combing or brushing hair
if you have face pain
Do you ever have a sudden brief pain in the same spot in your face or mouth with a machine gun-like repetition? Yes No
Can people see you wince or jump with attacks? Yes No
Are pain jabs identical in sensation and internsity(stereotypic)? Yes No
No pain symptoms except during attacks? Yes No
if you have scalp pain
Does combining or brushing your hair trigger the pain? Yes No
Have you ever hit your head or scalp at the place you now feel the pain? Yes No
if you have pain at the base of your skull
Does pressure on the back of your skull (i.e., resting your head on a pillow) trigger sharp pain or hurt the spot? Yes No
Does sudden twisting or bending of your neck trigger sharp pain or aggravate local soreness at the back of your head? Yes No
Can the pain spread from the back of your head over your scalp, ending above or behind the eye? Yes No
does the pain cause your eye to water or tear? Yes No

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