Patient Headache History

This page allows you to create an outline of your headache history to print and take with you to your doctor

Name:    Age: yrs.

Headache Description:

1. Onset

     I have had headaches now for years.

    My headaches started at age: under age 20 age 20-30 age 31-50 over age 50 choose age range

2. Initial Cause

   My headaches seemed to come on after an injury 

            Injury type:  Injury Date:

    My headaches seemed to come on after an event: Infection Pregnancy Emotional stress other choose event type

    My headaches came on spontaneously without an injury or event

3. Frequency of headaches

    My headaches occur 1 2 3 4 5 6 times per year month week day

    My headaches are staying the same increasing decreasing in frequency.

4. Location of headaches

    My headaches usually affect the right side the left side one side or the other all over no specific part of my head.

5. Duration of headaches:

    My headaches are continuous and never go away. come and go.

    On average my headaches that come and go last     hours minutes if treated 

                                                                        and   hours minutes if not treated.

6. Precipitating factors:

    My headaches can be brought on by (check all appropriate):

    fatigue    stress/tension    oversleeping   certain foods   alcohol   medications

    menstruation    coughing    shaving or touching my face     chewing   talking

    lying down    stooping over    exercise    sexual activity    other

7. Hormonal (women only)

    My headaches are not affected by worstened by relieved by my menstrual cycle.

    Pregnancy: My headaches were not affected worstened relieved never pregnant

8. Seasonality

    My headaches are worse in the spring worse in the summer worse in the winter not seasonal .

9. Prodromata:

    Before my headaches I may get the following warning signs (check all that apply):

    halos in my vision    blind spots in my vision    flashing lights in my vision

    upset stomach        a feeling of tightness around my head    dizziness

    lightheaded        numbness in an arm or leg    other symptoms

10. Pain type or quality (not severity):

    The majority of my headaches feel throbbing dull sharp stabbing burning other than these choices

11. Severity:

    My usual headache is mild to moderate severe very severe unbearable in intensity.

    My headaches usually don't prevent prevent normal activities such as work.

12. Family History:

    Family members with headaches (check all that apply)

    mother    father    sister(s)    brother(s)    children    more distant relatives

13. Associated Symptoms

    Accompanying my headaches I often get the following symptoms (check all that apply):

    nausea & vomitting    light sensitivity    noise sensitivity    eye tearing

    runny nose or nasal stuffiness    ringing in the ears    insomnia    stiff neck

    disturbance of my vision    numbness or tingling    frequent or early awakenings from sleep

14. Previous care:    Other doctors I've seen for headache treatment:

     Dr.

     Dr.

     Dr. 

    I've had the following tests regarding my headaches (check all that apply):

    CT or CAT scan   MRI scan  EEG   Skull x-rays Lumbar puncture (spinal tap)

    angiograms    sinus x-rays    eye exam    Psychological counseling or testing

   Medications I've taken for my headaches include the following:

   Intermittent therapy

   tylenol/advil/aspirin/anacin                                                        

   tylenol or aspirin with codeine (e.g. tylenol #3, 222, 292)

   Fiorinal    Opioids (e.g.morphine, codeine alone,                    

                                         oxycodone, darvon, leritine)

   Torodol    Naproxen    Indocid                                           

   Imitrex    zomig    maxalt    amerge                             

   cafergot  ergomar bellergal spacetabs                           

   Prophylactic therapy

   Inderal (propranolol)   timolol                                                                   

   amitriptyline (elavil),     imipramine                                          

`  sibelium   verapamil                                                             

   valproic acid                                                                             

   lithium carbonate                                                                                 

   sansert    sandomigran                                                       

   Other medications I've used:

   Other therapies I've used (e.g. biofeedback, chiropractic, massage)

Print this form out and submit it to your doctor when you see him or her for your appointment.

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 (c) Neurology BC 2001 www.dendrite.ca