Headache Diary
A headache diary is a crucial tool that can help you and your healthcare provider to keep track of the frequency, severity, and span of your headaches; identify the triggers, and monitor the responses to the acute and preventative medications. Please fill out this form each day you experience a headache.
Name
First Name
Last Name
Gender
Male
Female
Transgender
Non-binary
Other
Please specify the following information about your headache.
Date
 -
Month
 -
Day
Year
The date you experienced the headache
Time
Hour Minutes
AM
PM
AM/PM Option
Duration
Please specify in minutes.
Were you on your menstrual period on that date?
Yes
No
Not applicable
The pain was
Dull
Throbbing
Pulsing
Sharp
Piercing
Other
Location of the pain
On the left side
On the right side
At the back
At the front
Behind the eyes
Other
Intensity of the pain
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Have you taken any medications to prevent the headache?
Yes
No
Name of the medication
Number of doses taken
Tablets/injections per day
Name of the medication
Number of doses taken
Tablets/injections per day
Have you taken any medications to treat the headache?
Yes
No
Name of the medication
Number of doses taken
Tablets/injections per day
Name of the medication
Number of doses taken
Tablets/injections per day
Other activities done to intervene/provide relief
Please select the triggers that might caused your headache
Lack of sleep
Caffeine intake
Alcohol intake
Skipping a meal/ Hunger
Being exposed to a bright light
A certain smell
Consuming a certain type of food
Other
Please specify
Please select the headache sypmtomps you have experienced
Sensitivity to light, smells or sound
Nausea
Dizziness
Personality change
Numbness
Other
Please indicate your disability for the day
Able to conduct daily/regular activities without any difficulty
Difficulty in conducting daily/regular activities
Unable to conduct daily/regular activities and leave the bed
Save
Should be Empty: