Pre Treatment Migraine Headache Questionnaire Page 2
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47. Are your migraines affecting your sleep?
Yes
No
8. How would you describe your migraine headaches? (Check all the apply)
Throbbing/Pounding
Ache/pressure
Like a tight band
Dull
Other______________
9. Do your migraine headaches awaken you at night?
Never
Occasionally
Often
10. Do any of the following occur before or during your migraine headaches? (Check all that apply)
Nausea
Runny Nose
Diarrhea
Bothered by light
Vomiting
Sparkling, flashing, or colored lights
Bothered by noise
Blurred/double vision
Loss of vision
Eyelid puffy
Eyelid droops
Weakness of arm or leg
Feeling lightheaded
Numbness/ tingling
Loss of consciousness
Difficulty concentrating
Speech difficulty
Other_____________________
11. Do any of the following trigger your migraine headaches or make them worse? (Check all the apply)
Stress
Bright sunshine
Heavy lifting
Letdown after stress
Loud noise
Certain smells or perfume
Air travel
Fatigue
Coughing, straining, or bending over
Missed
Sexual activity
Other___________________
Certain foods
Weather changes
12. Do any of the following make your migraine headaches better?
Rest
Exercise
Hot compress
Massage
Cold compress
Quiet and darkness
Pressure over migraine headache area
Warm shower
Other___________________
13. 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
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Parent category: Life