Headache Diary
Name:
Month:
Year:
DATE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Morning
Afternoon
Headache
Severity
Evening/Night
Scale of 0-10
No pain = 0
1
2
3
4
5
6
7
8
9
10 = Pain as bad as it could be
SYMPTOMATIC MEDICATIONS (Tablets/injections per day) (Medications taken to treat a headache eg. Triptans, painkillers, etc.)
Name: ___________/____mg
Overall relief
Name: ___________/____mg
Overall relief
Name: ___________/____mg
Overall relief
Name: ___________/____mg
Overall relief
Relief: 0-1-2-3
0 = None 1 = Slight Relief
2 = Moderate Relief
3 = Complete Relief
PREVENTATIVE MEDICATIONS (Daily medications taken to prevent or decrease your headache tendency eg. Amitriptyline)
Name: ___________/____mg
Name: ___________/____mg
MENSTRUAL PERIODS
DISABILITY FOR THE DAY
0 = None
1 = Able to carry out usual activities fairly well
2 = Difficulty with usual activity, may cancel less important ones
3 = Have to miss work (all or part of day) or go to bed for part of day
TRIGGERS
Please code trigger with a number and give details below. Record trigger number in table above on the appropriate date where you feel that trigger contributed to your headache.
1
2
3
4.
(Please turn page over and complete the other side)