Headache Journal

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Headaches and Trigger Points
Headache Pain Treatment Publications

Symptom                                      |     Yes   |    No    |      Sometimes     |                Comments/Notes             
 
The Pain occurs in:
Right Eye
Left Eye
Both Eyes
Forehead
Right Temple
Left Temple
Both Temples
Temple and Jaw
Back of Head and Neck
Front of Head and Teeth
Other
 
Vision:
My Vision Blurs in Left Eye
My Vision Blurs in Right Eye
My Vision Blurs in Both Eyes
I Lose Vision in One/Both Eyes
 
My Headaches Occur
Daily
2 - 3 Times Weekly
4-6 Times Weekly
Before my Menstrual Cycle
During my Menstrual Cycle
After my Menstrual Cycle
 
Headaches occur when:
I exert myself
When I am at rest
Both
 
Headaches Cause Sensitivity to:
Light
Sound
Odors
All of the above
 
I Experience:
Nausea
Vomiting
Sinus Congestion
Sinus Draining
Tooth Pain
Dizziness
Diarrhea
Constipation
Confusion
Depression
Anxiety
 
Foods Consumed before the Headache Occured
Wheat products. (bread, rolls, pizza, pitas, cereal, cookies)
Sugar (Donuts, cookies, hard candy, soda)
Dairy (milk, ice cream, cottage cheese, cheese)
Chocolate
Wine
Beer
Other alchohol
Coffee/Tea
Soda
Diet Soda
 
I have been checked for a sleep disorder
 
I have recently had my blood pressure checked
 
I have been tested for TMJ (Temporomandibular Joint Disorder)
 
I am currently taking medication for my headaches
 
I am currently taking medications for another condition
 
I sleep
Eight hours a night
Five hours a night
I twilight sleep all night
I wake up every few hours
I fall asleep immediately but wake up easily and toss and turn.
I have no trouble sleeping
I sleep all night unless I am experiencing my menstrual cycle.

 

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