Headache Journal Template


Headache Journal
Name: _____________________________________
This journal includes one chart for each month. Please make a notation every day. If
your child has no headache, simply put a zero (0) on the appropriate date. On days your
child has a headache please write down: how severe the pain is, if you notice any triggers,
how long the headache lasts, any associated symptoms, and any medications your child
took for the headache.
Coding Information:
Severity Scale: Please ask your child to rate his/her pain on a scale from 0
to 10, with 0 being no pain and 10 being the worst.
Associated Symptoms:
Nausea and/or Vomiting
Light Sensitivity (Lights hurt or make the headache worse)
Noise Sensitivity (Noises make the headache worse)
Visual disturbance (child see spots or things look “weird”)


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