Download Your Migraine Diary
Download Your Migraine Diary
Download Your Migraine Diary
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
SUMMARY OF YOUR MONTH<br />
YOU SHOULD COMPLETE THIS AT THE END OF YOUR MONTH.<br />
There are six pages of Headache Reports for you to use to report details<br />
of your headache attacks, and you should complete these<br />
first before filling in this summary page.<br />
YOUR MONTH<br />
What prescribed medicine, if any, have you taken for your<br />
headache during the past month?<br />
How many ‘severe’ headaches did you have during the<br />
last month?<br />
Which was the worst of the headaches you reported?<br />
(Headache number)<br />
How many days did you miss from work due to headache?<br />
On how many days were you stopped from doing everyday<br />
activities by your headache?<br />
How many social events did you miss due to headache?<br />
Approximately how many tablets of any prescribed<br />
headache treatment have you taken during the last month?<br />
Would you take this medicine again? Yes No
HEADACHE REPORT<br />
HEADACHE 1<br />
Time it started<br />
Date of headache<br />
Time it finished<br />
/ /<br />
Please circle the number to indicate how bad your symptoms were<br />
during your attack.<br />
(0 indicates no symptoms and 10 indicates most severe symptoms)<br />
Severity of the HEADACHE overall<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
Severity of the NAUSEA/SICKNESS<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
Severity of the SENSITIVITY TO LIGHT AND/OR NOISE<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
How severely did the headache affect your LIFE AND ACTIVITY?<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
How long after your headache attack started were you able to return<br />
to normal activities?<br />
hours<br />
What medication did you take for this attack?<br />
(include medicines you buy yourself as well as those prescribed by your doctor)<br />
How much did you take?<br />
(prescribed medicine)<br />
(bought by yourself)<br />
When did you take it?<br />
Within the first hour After 1-2 hours Other<br />
How many minutes did it take to work?<br />
Do you think anything triggered this attack?
HEADACHE REPORT<br />
HEADACHE 2<br />
Time it started<br />
Date of headache<br />
Time it finished<br />
/ /<br />
Please circle the number to indicate how bad your symptoms were<br />
during your attack.<br />
(0 indicates no symptoms and 10 indicates most severe symptoms)<br />
Severity of the HEADACHE overall<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
Severity of the NAUSEA/SICKNESS<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
Severity of the SENSITIVITY TO LIGHT AND/OR NOISE<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
How severely did the headache affect your LIFE AND ACTIVITY?<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
How long after your headache attack started were you able to return<br />
to normal activities?<br />
hours<br />
What medication did you take for this attack?<br />
(include medicines you buy yourself as well as those prescribed by your doctor)<br />
How much did you take?<br />
(prescribed medicine)<br />
(bought by yourself)<br />
When did you take it?<br />
Within the first hour After 1-2 hours Other<br />
How many minutes did it take to work?<br />
Do you think anything triggered this attack?
HEADACHE REPORT<br />
HEADACHE 3<br />
Time it started<br />
Date of headache<br />
Time it finished<br />
/ /<br />
Please circle the number to indicate how bad your symptoms were<br />
during your attack.<br />
(0 indicates no symptoms and 10 indicates most severe symptoms)<br />
Severity of the HEADACHE overall<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
Severity of the NAUSEA/SICKNESS<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
Severity of the SENSITIVITY TO LIGHT AND/OR NOISE<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
How severely did the headache affect your LIFE AND ACTIVITY?<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
How long after your headache attack started were you able to return<br />
to normal activities?<br />
hours<br />
What medication did you take for this attack?<br />
(include medicines you buy yourself as well as those prescribed by your doctor)<br />
How much did you take?<br />
(prescribed medicine)<br />
(bought by yourself)<br />
When did you take it?<br />
Within the first hour After 1-2 hours Other<br />
How many minutes did it take to work?<br />
Do you think anything triggered this attack?
HEADACHE REPORT<br />
HEADACHE 4<br />
Time it started<br />
Date of headache<br />
Time it finished<br />
/ /<br />
Please circle the number to indicate how bad your symptoms were<br />
during your attack.<br />
(0 indicates no symptoms and 10 indicates most severe symptoms)<br />
Severity of the HEADACHE overall<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
Severity of the NAUSEA/SICKNESS<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
Severity of the SENSITIVITY TO LIGHT AND/OR NOISE<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
How severely did the headache affect your LIFE AND ACTIVITY?<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
How long after your headache attack started were you able to return<br />
to normal activities?<br />
hours<br />
What medication did you take for this attack?<br />
(include medicines you buy yourself as well as those prescribed by your doctor)<br />
How much did you take?<br />
(prescribed medicine)<br />
(bought by yourself)<br />
When did you take it?<br />
Within the first hour After 1-2 hours Other<br />
How many minutes did it take to work?<br />
Do you think anything triggered this attack?
HEADACHE REPORT<br />
HEADACHE 5<br />
Time it started<br />
Date of headache<br />
Time it finished<br />
/ /<br />
Please circle the number to indicate how bad your symptoms were<br />
during your attack.<br />
(0 indicates no symptoms and 10 indicates most severe symptoms)<br />
Severity of the HEADACHE overall<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
Severity of the NAUSEA/SICKNESS<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
Severity of the SENSITIVITY TO LIGHT AND/OR NOISE<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
How severely did the headache affect your LIFE AND ACTIVITY?<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
How long after your headache attack started were you able to return<br />
to normal activities?<br />
hours<br />
What medication did you take for this attack?<br />
(include medicines you buy yourself as well as those prescribed by your doctor)<br />
How much did you take?<br />
(prescribed medicine)<br />
(bought by yourself)<br />
When did you take it?<br />
Within the first hour After 1-2 hours Other<br />
How many minutes did it take to work?<br />
Do you think anything triggered this attack?
HEADACHE REPORT<br />
HEADACHE 6<br />
Time it started<br />
Date of headache<br />
Time it finished<br />
/ /<br />
Please circle the number to indicate how bad your symptoms were<br />
during your attack.<br />
(0 indicates no symptoms and 10 indicates most severe symptoms)<br />
Severity of the HEADACHE overall<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
Severity of the NAUSEA/SICKNESS<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
Severity of the SENSITIVITY TO LIGHT AND/OR NOISE<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
How severely did the headache affect your LIFE AND ACTIVITY?<br />
☺ 0 1 2 3 4 5 6 7 8 9 10 ☹<br />
How long after your headache attack started were you able to return<br />
to normal activities?<br />
hours<br />
What medication did you take for this attack?<br />
(include medicines you buy yourself as well as those prescribed by your doctor)<br />
How much did you take?<br />
(prescribed medicine)<br />
(bought by yourself)<br />
When did you take it?<br />
Within the first hour After 1-2 hours Other<br />
How many minutes did it take to work?<br />
Do you think anything triggered this attack?
Change language