The Headache Healer’s Handbook. Jan Mundo

use, significant life events, and more. Your responses will form your baseline and will be used again at the end of the program to evaluate your progress.

      The headache history questions are designed not only to provide baseline information but to help you begin the inquiry process of looking at your headaches in a new light. Some questions might awaken memories and reveal decisions made long ago that impact you today. Be open, and let the process spark your curiosity and provide new clues. By examining the details and aspects of your life in order to discover their connections, you are embarking on the foundational practice of the headache healer.

Headache History Questionnaire

      Complete the questionnaire. Use separate or additional paper if you wish.

       1. Date: _________________________

       2. Name: _____________________________________________

       3. Status (circle): Single Married Partnered Divorced Widowed

       4. Children’s names/ages: ________________________________________________________________________

       5. Occupation: _________________________________________

       6. a. Number of years at your work or job: _____

       b. Do you like your work? yes _____ no _____

       7. a. Age now: _____

       b. Age at onset: _____

       c. Number of years with headaches: _____

       8. a. Height: _____

      b. Weight: _____

       9. Circle the type(s) of headaches you have:

       tension-type headache

       migraine without aura

       migraine with aura

       migraine with symptoms of tension-type headache

       tension-type headache with symptoms of migraine

       menstrual migraine

       menstrual-related migraine

       medication-overuse headache

       cluster headache

      10. Describe where your headache pain is usually located: ______________________________________________________________________

      11. How often do you get headaches?

       # per week: _____ or # per month: _____ or # per year: _____

      12. How long do your headaches usually last?

       # of minutes: _____ or # of hours: _____ or # of days: _____

      13. Circle all symptoms you get before a migraine, during the premonitory phase / prodrome:

       anxiety

       constipation

       depression

       diarrhea

       disorientation

       dizziness

       face pain

       fatigue

       frequent urination

       hallucinations

       head pain

       hyperactivity

       insomnia

       light sensitivity

       loss of appetite

       mood changes

       nausea

       neck pain

       shoulder pain

       smell sensitivity

       sound sensitivity

       stuffy nose

       touch/skin sensitivity (allodynia)

       visual changes

       visual distortion

       vomiting

       yawning

       other (describe): ______________________________________________

      14. How long before your headaches start do these symptoms typically occur? _________________________________________________

      15. If you have migraine with aura, describe your aura symptoms: _________________________________________________________

      16. Circle the word(s) that best describe your typical headache pain:

       aching

       band-like

       beating

       boring

       constant

       drilling

       dull

       gripping

       hurting

       intermittent

       painful

       piercing

       poking

       pounding

       pulsating

       sharp

       shooting

       sore

       stabbing

       stake-like

       steady

       tender

       throbbing

       tight

       viselike

      17. Indicate the usual intensity of your headaches by circling a number on the pain scale:

0	1	2	3	4	5	6	7	8	9	10
|										|
No pain	Most intense pain imaginable

      18. Circle other symptoms you get during a headache:

       anxiety

       appetite loss

       back pain

       constipation

       depression

       diarrhea

       dizziness

       face pain

       fatigue

       general pain

       hallucinations

       lethargy

       light sensitivity

       mood changes

       nausea

       neck pain

       scalp pain

       shoulder pain

       sinus pain

       smell sensitivity

       soreness

       sound sensitivity

       tenderness

       touch/skin sensitivity (allodynia)

       visual changes

       vomiting

       other (describe): ____________________________________________

      19. Do you wake up with headaches? yes _____ no _____

      20. Circle any factors that seem to trigger your headaches:

       Dietary

       aged cheeses

       alcohol / alcoholic beverages

       artificial sweeteners

       beans