My headaches started on: I get headaches about every: day week month three-months year My headaches last: seconds minutes hours days Describe the head pain you experience
- throbbing
- pulsating
- pounding
- constant
- tight
- squeezing
- pressure
- sharp
- grinding
- vise-like
- hat-band
- tender
- other:
- My headaches are located
- Headache is accompanied by
- diarrhea
- dizziness
- drooping eye lid
- facial tenderness
- fever
- flushing on one side of the face
- light sensitivity
- loss of consciousness
- nausea or vomiting
- neck stiffness
- noise sensitivity
- numbness in face/arm/leg
- red, tearing eye
- runny nose/congestion
- swelling of ankles
- speech disturbance
- visual disturbances
- weakness in face/arm/leg
- other:
- other:
- Alcohol
- Barometric pressure or weather
- Bending over
- Blood Pressure
- Certain foods (such as cheese or Chocolate)
- Colds
- Coughing
- Depression, anxiety, nerves, or stress
- Exertion
- Fatigue
- Heat, hot showers
- Head movement
- Menstrual periods
- Missing a meal
- Monosodium glutamate (MSG)
- Odors
- Salt
- Sex
- Seasons
- Swallowing
- Sleep or Lack of sleep
- Time of day
- Cold compresses
- Eating
- Heat
- Massage
- Medication (which ones ?)
- Moving around
- Relaxation
- Sleep
- Vomiting
- How many alcoholic drinks per day ?
- How many caffeinated drinks per day
- How many hours do you sleep per day ?
- Do you smoke cigarettes, cigars or pipes ?
- Are you currently involved in litigation with respect to any medical problems ?
- Are you usually highly stressed ?
- Do you usually eat 3 meals/day ?
- head
- neck (for example whiplash)
- dental work preceding onset of headache ?
- Carbon Monoxide (car or house)
- Venereal Disease or Syphilis ?
- Tuberculosis or Cysticercosis ?
What are your current medications, include hormones, birth control pills, vitamins, etc. (Name and amount/day Have you ever taken any of the following medicines for headache
- Abilify
- DHE
- Mexetil
- Sinutab
- Adipin
- Duradrin
- Micranin
- Skelaxin
- Acetaminophen
- Duragesic
- Midol
- Soma
- Advil
- Ecotrin
- Midrin
- Stadol Nasal Spray
- Alleve
- Effexor
- Migranol
- Sumatriptin (triptan)
- AlkaSeltzer
- Elavil (amitryptyline)
- Motrin
- Surmontil
- Amerge (triptan)
- Empirin
- Naprosyn
- Talwin
- Amitriptyline
- Ergomar (ergot)
- Neurontin
- Tenormin
- Anacin
- Ergostat (ergot)
- Nimodipine
- Thorazine
- Anafranil
- Esgic
- Norflex
- Timonol
- Antihistamines
- Equigesic
- Norgesic
- Topamax
- Asendin
- Excedrin
- Norpramin
- Toprol
- Aspirin
- Fentanyl patch
- Nortriptyline
- Torecan
- Axert (triptan)
- Feverfew
- Nubain
- Trexan
- Axotal
- Fiorinal
- Nuprin
- Triavil
- Aventyl
- Fioricet
- Oxygen
- Trilifon
- Baclofen
- Flexeril
- Oxycontin
- Trileptal
- Bellergal
- Gabapentin
- Pamelor
- Tylox
- Beta-blocker
- Ibuprofen
- Panadol
- Tylenol
- Blockadren
- Imitrex
- Parafon Forte
- Tylenol #3 or #4
- Bufferin
- Inderal (propranolol)
- Parnate
- Vanquish
- Cafergot
- Indocin
- Paxil
- Venlafaxine (Effexor)
- Calan (verapamil)
- Indomethacin
- Pertofrane
- Verapamil (Calan)
- Cardene
- Isoptin
- Percocet
- Verelan (verapamil)
- Cardizem
- Lamictal
- Percodan
- Viskin
- Catapres
- Lexapro
- Percogesic
- Vivactyl
- Corguard
- Limbitrol
- Periactin (cyproheptadine)
- Vicodin
- Codeine
- Lithium
- ohenergan
- Wellbutrin
- Cymbalta
- Liorisal
- Phrenilin
- Wigraine
- Cyproheptadine
- Lopressor
- Procardia
- Zomig
- Darvon/Darvocet
- Lortabs
- Propranolol (inderal)
- Zonegran
- Datril
- Lorcet
- Prozac
- Zoloft
- Dapro
- Ludiomil
- Reglan
- Desyril
- Lyrica
- Relpax (triptan)
- Herbal products
- Dilantin
- Magnesium
- Robaxin
- Petadolex
- Decongestants
- Marplan
- Serzone
- Demerol
- Maxalt (triptan)
- Sansert
- Depakote
- Methadone
- Sinequan
My health has been affected by Treatment by a
- General Health
- psychiatrist
- Lyme disease
- Problems
- or counselor