HeadacheOrMigraine

Headache or Migraine Evaluation Tool

1 How often do you experience headaches?
  Less than once a month
  Once or twice a month
  Three or more times a month
2 Which of the following best describes your headaches?
  A throbbing or pulsing sensation
  A heaviness, pressure or tightness
3 Are your headaches accompanied by nausea or vomiting?
  Yes
  No
4 Are your headaches accompanied by sensitivity (increased pain) when exposed to light?
  Yes
  No
5 Do your headaches interfere with your normal routine, for example would you find it hard to walk or move around when you have a headache?
  Yes � always
  Yes � sometimes, if it�s a bad one
  Not usually
  Never
6 Can you predict when you will get a headache, for example after being out in the sun, after drinking too much coffee, or after a bad night�s sleep?
  Yes
  No
7 During a headache, do you feel pain or pressure
  On both sides of your head at the same time
  Mainly on one side of your head
8 Are your headaches accompanied by a loss of vision or other unusual visual symptoms such as flickering lights or zigzag lines?
  Yes
  No
9 Do you rely on medication to control or ease your headaches?
  Yes � always
  Yes – sometimes
  Never
10 On the scale below, please indicate how much you feel your quality and enjoyment of life is affected by your headaches (1 indicates that your life is not affected by the headaches and 10 indicates your life is severely affected)
1 2 3 4 5 6 7 8 9 10

This information will be collected for educational purposes, however it will remain anonymous.