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Headache questionnaire - Enfield Neurology

By Jeremy Hayes,2015-01-15 05:06
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Headache questionnaire - Enfield Neurology

    Ira Pollack MD Board certified Neurology, Neurophysiology, Sleep Disorders 139 Hazard Ave. Bldg 1 Unit 2, Enfield, CT 06082 pollackira@sbcglobal.net (860) 749-5881

    Headache questionnaire

    Name ________________________________ Date _______________ Age __________

    How long have you suffered from headaches? _____ weeks / months / years

    Age at onset of headaches ________ years old

    Childhood headaches?

    Cyclic vomiting or unexplained vomiting in childhood?

    Family history of migraine? ___________________________________________________

    Family history of headache? ___________________________________________________

Usual headaches: (If you do not have milder headaches, skip this section)

    Approximate frequency: 1x/month 1x/week 2-4x/week daily constant

    Side: both sides right side left side changing sides (sometimes R, sometimes L)

    Location: eye forehead temple top of head face/cheek neck

    Quality: pounding throbbing boring aching tight band shooting pressure

    Associated complaints flashing lights blurred vision dizziness nausea vomiting

    Circle average severity: 1 2 3 4 5 6 7 8 9 10

    Severe headaches:

    Approximate frequency: 1x/month 1x/week 2-4x/week daily constant

    Duration of headaches: brief 30-60 mins 1-2 hrs 3-6 hrs 6-24 hrs days

    Side: both sides right side left side changing sides (sometimes R, sometimes L)

    Starting location: eye forehead temple top of head back of head face ear neck

    Overall location: eye forehead temple top of head back of head face ear neck

    Quality: pounding throbbing boring aching tight band shooting pressure

    Associated complaints: flashing lights blurred vision dizziness nausea vomiting

    Neurologic deficits: blindness one-sided paralysis vertigo numbness

    Circle average and maximum severity: Mild 1 2 3 4 5 6 7 8 9 10 Worst imaginable

    Do you also have milder headaches in between your severe headaches? Yes No How do you identify a severe headache starting? __________________________________ Are there warning signs before the headache pain starts? ____________________________

    How many headache-free days per week do you have? 1 2 3 4 5 6 7 Associated symptoms with headaches

    Tearing from one eye Ear pain

    Drainage from one nostril Paralysis

    Swelling of face Numbness

    Droopy eyelid Muscle spasm

    Red eye

    Factors which worsen the headaches

    Light Bending over

    Sound Exertion

    Movement Sexual intercourse

Medication trials: list dose and response

    Ibuprofen, Advil, Indocin, Indomethacin Aleve, arthritis medications

    Aspirin, Tylenol, Excedrin Tylenol #3, codeine, Ultracet Percocet

    Fiorinal, Fioricet, butalbital Midrin

    Imitrex tablets nasal spray injection Relpax Axert Zomig Maxalt

    Stadol nasal spray Cafergot, DHE Migranal nasal spray

    Amerge, Frova Namenda, Aricept

    Inderal, Toprol, atenolol Verapamil / Calan

    Depakote Topamax

    Keppra Neurontin

    Elavil, amitriptyline, nortriptyline Prozac, Paxil, Wellbutrin, Effexor

    Zanaflex, Skelaxin, Soma, Flexeril Antibiotics, Flonase, antihistamines

    Other: ____________________________________________________________________________

    What alternative treatments have you tried? What was the response?

    Acupuncture Botox injections

    Chiropractor herbs, homeopathy

    TENS - Electrical stimulation units relaxation, yoga, meditation, reflexology

    Other__________________________________________ Air purifier (e.g. Ecoquest)

    Headache triggers

    Foods:

    Cheese wine/alcohol pickles chocolate sausage yogurt

    MSG/Chinese food aspartame diet foods sandwich meats

    Other:

    Nitroglycerine nifedipine

    Oversleeping sleep deprivation

    Missing meals exertion reading

    Menstrual cycle sex

    Allergy/sinus problems viral infections, colds, flu perfume

    Fever

    Changes in weather sunlight

    Caffeine intake caffeine-withdrawal

    Touching the face wind in the face

    Chewing chewing gum swallowing eating ice cream

    How fast does alcohol trigger a headache? 1 hour 2-4 hours 6 hours or more No effect on headache

    Caffeine intake: ______ cups coffee, ___ cups tea, ____ cola per day ___ None Do you take any supplemental calcium? Y/N Niacin? Y/N

    Sleep schedule

    Bed time _____ Lights out _____

    Awake _____ Out of bed _____

    Awakenings per night _____ Naps (hours) _____

    Hours per day in recliner or sofa _____ hours

    How many days work/school have you missed in the last month due to headache? _____ How often do you go to the emergency room for headaches? _____________________________

    How many Tylenol, Tylenol #3, aspirin, naproxen, or ibuprofen do you take per week? _____ How many Imitrex or other headache drugs do you take per week? _____

Stress

     Work Family Financial Death in family Illness

What time of day do you usually get headaches?

    Morning Afternoon Night There is no pattern

    Are your headaches worse, better or unchanged with lying down?

    Are your headaches worse, better or unchanged with standing up?

    Are your headaches seasonal? ________ Season(s)_______________________ Do you have allergies? ______ Seasonal allergies only? ________ year-round? _____

    Allergy medications: ___________________________________

    How many significant sinus infections (with fever, thick nasal discharge, facial congestion and facial pain)

    do you get per year? _________

    Nasal blockage, difficulty breathing through nose:

    Right-sided blockage Left-sided blockage Both sides blocked

Have you been diagnosed with any of the following?

    Deviated Nasal Septumf Allergic Rhinitis

    Nasal/Sinus Polyps Facial Fracture

    Obstructive sleep apnea

Do you have

    neck pain tongue pain

    neck or shoulder pain radiating to the arm dental abscess

    jaw pain with chewing tooth pain

    Which neurologists or other specialists have you seen for your headaches? ______________________________________________________________________________ Please list any diagnostic tests and approximate dates performed (CT Scans, MRI, etc): ______________________________________________________________________________

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