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Headache Diary

Month of: _________________________
Name: ____________________________

Severity Scale:
0 - Headache-free
1 - Mild headache, allowing normal activity
2 - Moderate headache, disturbing but not preventing normal activity
3 - Severe headache, normal activity is impossible. Bed rest may be necessary.
 

Relief Measures:

bullet Ice pack
bullet Bed rest
bullet Dark room
bullet Medication (list name and dosage)
bullet Relaxation techniques
bullet Other (please specify)

Headache Triggers:

bullet Alcohol
bullet Chocolate
bullet Aged cheese
bullet Citrus fruits
bullet Cured meats
bullet MSG
bullet NutraSweet
bullet Skipped meals
bullet Nuts
bullet Onions
bullet Salty foods
bullet Excess caffeine
bullet Stress
bullet Fatigue
bullet Missed medication
bullet Eyestrain or other visual triggers

Headache Diary (Circle dates of menstrual flow):

Date Severity Relief Measures Headache Triggers
1      
2      
3      
4      
5      
6      
7      
8      
9      
10      
11      
12      
13      
14      
15      
16      
17      
18      
19      
20      
21      
22      
22      
23      
24      
25      
26      
27      
28      
29      
30      
31      

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Based on a publication from the American Council for Headache Education (ACHE) entitled "Why Does My Head Hurt?"
 
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