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Maia U. Chakerian, MD
Silicon Valley Pain Center

MIGRAINE/HEADACHE QUESTIONNAIRE
PLEASE PRINT
Name: ________________________________ Date: __________________________
1) AGE: How old were you when you had your first migraine headache?____________
a) For Females: Was it with onset of menstruation (period)?____________________
b) Was there any specific event that occurred that you could relate to the onset of
migraines, or did it come on gradually?
___________________________________________________________________
___________________________________________________________________
2) PAST HISTORY:
a) Does anyone else in your family (i.e. mother, father, grandparents, or other family
members) have migraine headaches?
___________________________________________________________________
b) Have you ever been formally evaluated for your headaches? __________________
i) If yes, By whom and when? __________________________________________
ii) Was the doctor a neurologist?________. If not, indicate what type of specialist
diagnosed your migraine.___________________________________________
iii) Did you ever have a CT scan or MRI scan of your head? __________________
---If yes, what were the results?
_________________________________________________________________
_________________________________________________________________
c) Over the past 5 years, have your headaches worsened? Stayed the same? Improved?
___________________________________________________________________
d) Do you get chronic daily headaches or tension headaches in addition to
migraines? __________. If yes, please describe.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
3) FREQUENCY: How many times per month do you get a migraine headache?
_____________________________________________________________________
4) DURATION: How long does your headache last (in days)? ___________________
5) SEVERITY: On a scale of 1-10 (with 10 being the worst), how would you rate your
headache pain? ______________________________________________________
Headache questionnaire
14601 S. Bascom Ave. Ste. 240
Los Gatos,Ca 95032
Telephone. 408-356-0503
Page 1 of 4


Maia U. Chakerian, MD
Board Certified Specialist in Pain Medicine

6) DISTRIBUTION: Please describe specifically where on your body you typically get
the headache pain? For example: Is the pain on one side or both sides of your head?
Where does it usually start? Does it shift from side-to-side? Is it found behind your
eyes? Does the pain distribution also include your neck?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
7) Please describe any other specific or unusual details that might characterize your
headache.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
8) AURA: Definition: An aura is a “feeling of disconnection” prior to an actual migraine
headache. Do you typically experience an aura before your migraine headaches?____
If yes, please describe:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
9) ASSOCIATED SYMPTOMS: Please indicate whether you experience the following
Symptoms when you get migraine headache pain (yes or no):
a) Nausea? ___________ b) Vomiting? _________ c) Photophobia (sensitivity to light)? ______________ d) Phonophobia (sensitivity to sound)? _____________ e) Please describe any other associated symptom(s) that you may experience during a migraine headache: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Headache questionnaire
14601 S. Bascom Ave. Ste. 240
Los Gatos,Ca 95032
Telephone. 408-356-0503
Page 2 of 4

Maia U. Chakerian, MD
Board Certified Specialist in Pain Medicine

10) MEDICATIONS AND TREATMENTS:
a) Please list all current medications that you take for migraine headaches. Also
list any side effects you may be experiencing from use of this medication(s).
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
b) Please list all medications that you have taken in the past that for any reason
you are now unable to take, or which were not effective. Please list any side
effects you may have experienced.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
c) Do you currently take the drug IMITREX or similar type drug?______. If so,
does it relieve your headache? ________. How long does this drug provide
relief (in hours)?________. How long have you been taking Imitrex (or any
similar drug)?________. Do you find Imitrex (or similar drug) to be: a) more
effective; b) less effective; or c) just as effective now as when you first began
taking the medicine? _________. What side effect do you experience with
Imitrex or similar type drug?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
d) Other than medication, are there any other treatments (i.e. acupuncture or
homeopathic remedies) that you use to help relieve your migraine headache
pain? (Yes or No) __________. If yes, please describe:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

f) What do you do if medications do not relieve your headache?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Headache questionnaire
14601 S. Bascom Ave. Ste. 240
Los Gatos,Ca 95032
Telephone. 408-356-0503
Page 3 of 4
Maia U. Chakerian, MD
Board Certified Specialist in Pain Medicine
________________________________________________________________________
11) JOB/ LIFESTYLE:
a) If currently employed, approximately how much time (hour/month on
average) do you miss from work?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
b) How do migraine headaches affect planning for your daily activities?
________________________________________________________________________
________________________________________________________________________
c) How do migraine headaches affect your overall life?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
12) OTHER MEDICAL HISTORY:

a) Do you have any other medical problems?
(Please list)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
13) PLEASE LIST ALL MEDICATIONS TAKEN:
Name of Medication

Frequency
Date started Prescriber

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
14) ALLERGIES:
________________________________________________________________________
15) PAST SURGERIES AND DATES:
________________________________________________________________________
________________________________________________________________________
Headache questionnaire
14601 S. Bascom Ave. Ste. 240
Los Gatos,Ca 95032
Telephone. 408-356-0503
Page 4 of 4

Source: http://www.svpaindoc.com/webdocuments/migrainequestionnaire.pdf

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