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”)

Dizziness

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Parent category: Medical