Pre Treatment Migraine Headache Questionnaire Page 2
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210. Do any of the following bring on your migraine headaches or make them worse? (Check all that
apply)
Stress (worry, anger)
Bright Sunshine
Weather change
Letdown after stress
Loud noise
Heavy lifting
Air travel
Fatigue
Certain smells or perfume
Missed Meals
Sexual Activity
Coughing, straining, bending over
Certain foods (chocolate, cheese, beer, MSG)
Other: _______________________________
11. Do any of the following make your migraine headaches better?
Rest
Exercise
Quiet and darkness
Hot Compress
Cold Compress
Massage
Warm Shower
Pressure over migraine headache area
Other: __________________________________________________________________________
12. If you are female, do your migraine headaches change with the following? (Check all that apply)
Menstrual periods
Birth Control Pills
Pregnancy
Other hormonal drugs
13. Do any of your family members have migraine headaches?
No
Yes
If “yes”, please explain who: ________________________________________
14. Have you ever had a head or a neck injury requiring medical treatment?
No
Yes
If “yes”, please describe: ___________________________________________
15. Have you ever been diagnosed to h have any health disorder (e.g. high blood pressure, asthma, heart
disease, gastric ulcers)?
No
Yes
If “yes”, please list: _______________________________________________
16. Have you had your migraine headaches evaluated by a neurologist?
Yes
No
If yes, by Whom: ________________________________________________________
What were the diagnoses? (Check All that Apply)
Migraine
Tension-type
Cluster
Other:__________________
17. List all past tests you have had for your migraine headaches: _______________________________
18. List all past treatment(s) for your migraine headaches: ____________________________________
19. Are you taking any prescription drugs to treat your migraine headaches?
If yes, please list the medications:___________________________________________
How many times in the last month have you used the prescription medications?
_______________________________________________________________________
20. Are you taking any over-the-counter drugs to treat your migraine headaches: _______YES/NO_____
If yes, please list the medications: ___________________________________________
How many times in the last month have you used the over-the-counter medications?
_______________________________________________________________________
21. What is your estimated cost per month of your migraine headache medications and visits to the
physician? _________________________________________________________________________
22. How much of these medical expenses are covered by your health insurance? ___________________
23. How would you rate your general health in the last month? (Check one)
Excellent
Good
Fair
Poor
24. To what extent do your migraine headaches affect your quality of life? (Check one)
Extremely
Moderately
Very Little
Not at All
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