Multi-page Chart Creator

Page 1

Q01: What type of headache do you have?

Q02: How long have you experienced headaches?

Regular Headache: Significant Headache Debilitating Headache

Q3: How frequently do you get headaches?

Regular Headache

Significant Headache

Debilitating Headache

Q04: Where does your head pain typically start ?

Frontal Temporal Sphenoid Cheek Maxilla Nasal Glabella Orbital Coronal Parietal TMJ Mandible Sagittal Transverse Atlas Occipital Mastoid Trapezius

Q05: Does your headache start on one side?

 

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Q06: How long does your typical headache attack last?

Q07: How many headache attacks can you get in a day?

Q08: How would you describe your headache?

Q09: Do you have any of these symptom days before a significant headache (Prodroma)?

Q10: Do you get any of these warnings before imminent headache attacks (Aura)?

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Q11: Do you experience any of the following symptoms during headache attacks?

Q12: Do you notice any of the signs in your face during headache attacks?

Q13: Have you noticed any factors that may trigger headache attacks?

Q14: Does your headache get worse with these physical activities.?

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Q15: Do your headaches occur at a specific time?

Q16: Have you been diagnosed with the following conditions in the past that may cause headache?

Q17: Have you been diagnosed with the following conditions in the past that may relate to your headache?

Q18: Are your headaches related to your hormonal changes?

Q19: Do significant headaches run in your family?

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Q20: Have you been diagnosed with any of the following conditions that may complicate headaches?

Q21: What medications have you tried for your headache attacks? How effective are they?

not work: -  | half work: +/-  | mostly work: +  | side effect: s   Effectiveness
Medications To Relieve Headaches  - +/- + s
01. Ibuprofen (Advil,Motrin )
02. Naproxen (Aleve)
03. Diclofenac (Toradol, Cambia)
04. Dihydroergotamine (DHE, Migranal)
05. Ergotamine (Cafergot)
06. Sumatriptan (Imitrex)
07. Rizatriptan (Maxalt)
08. Eletriptan (Relpax)
09. Zolmitriptan (Zomig)
10. Almotriptan (Axert)
11. Ubrogepant (Ubrelvy)
12. Rimegepant (Nurtec)
13. Lasmiditan (Reyvow)
14. Metoclopramide (Reglan)
15. Promethazine (Phenergan)
16. Methylprednisolone (Solu-Medrol)
17. Dexamethasone (Decadron)
18. Prednisone (Aleve)
19. Prochlorperazine (Compazine)
20. Ondansetron (Zofran)
21. Aspirin + Caffeine + Butalbital (Fiorinal)
22. Acetaminophen + Caffeine + Butalbital (Fioricet)
23. Isometheptene, dichloralphenazone and acetaminophen (Midrin)
24. High-flow oxygen therapy

Q22 At what age do you start headache?

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Q23: What daily medications do you use or have used for headache prevention and how effective are they?

not work: -  | half work: +/-  | mostly work: +  | side effect: s   Effectiveness
Medications To Prevent Headaches  - +/- + s
01. Propranolol (Inderal)
02. Metoprolol
03. Lisinopril
04. Candesartan
05. Topiramate (Topamax)
06. Valproate Acid (Depakote)
07. Zonisamide (Zonegran)
08. Nortriptyline (Pamelor)
09. Amitriptyline (Elavil)
10. Pregabalin (Lyrica)
11. Gabapentin (Neurontin)
12. Venlafaxine (Effexor)
13. Duloxetine(Cymbalta)
14. Verapamil
15. Erenumab (Aimovig)
16. Fremanezumab (Ajovyl)
17. Galcanezumab (Emgality)
18. Eptinezumab (Vyepti)
19. Onabotulinumtoxin (Botox)
20. Lithium
21. Tizanidine (Zanaflex)
22. Cyproheptadine

Q24: Have you used any alternative remedies to manage headaches and how effective are they?

not work: -  | half work: +/-  | mostly work: +  | side effect: s   Effectiveness
Supplements To Suppress Headaches  - +/- + s
01. Caffeine
02. Vitamin B2 (Riboflavin)
03. Diclofenac (Toradol, Cambia)
04. Vitamin B6 (Pyridoxine)
05. Coenzyme Q10 (CoQ10)
06. Vitamin D
07. Magnesium
08. Melatonin
09. Zinc
10. Feverfew
11. Butterbur
12. Ginger
13. Turmeric
14. Valerian Root
15. Ginkgo Biloba
16. Omega-3 Fatty Acids (Fish Oil)
17. Probiotics

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Q25: Have you used any therapy to manage headaches and how effective are they?

not work: -  | half work: +/-  | mostly work: +  | side effect: s   Effectiveness
Therapy To Suppress Headaches  - +/- + s
01. Neuromodulation (Cefaly, gammaCore)
02. Cognitive Behavioral Therapy (CBT)
03. Trigger point injection
04. Dihydroergotamine (DHE, Migranal)
05. Occipital nerve block<
06. Acupuncture
07. Cold packs
08. Exercise
09. Sleep
10. Meditation
11. Physical therapy<
12. Massage
13. Chiropractic manipulation

Q26: In the past 3 months, how has headache affected your life?

  1 2 3 4 >5
01.  Days missed work/schoolwork
02.  Days missed from household choir.
03.  Days missed from family / social activity
04. Days missed from leisure activities
05. Days only partially functioning.

Q27: Have you undergone imaging (e.g., MRI/CT) for headaches?





Q28:Have you undergone lab tests for headaches?

01. Kidney function
02. Liver function
03. Thyroid function

Q29: What is your current age range?

Q30: What is your gender?