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:

1. Ice pack
2. Bed rest
3. Dark room
4. Medication (list name and dosage)
5. Relaxation techniques
6. Other (please specify)

Headache Triggers:

1. Alcohol
2. Chocolate
3. Aged cheese
4. Citrus fruits
5. Cured meats
6. MSG
7. NutraSweet
8. Skipped meals
9. Nuts
10. Onions
11. Salty foods
12. Excess caffeine
13. Stress
14. Fatigue
15. Missed medication
16. 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