Migraine Assessment Form
Personal Information
Name
*
Email
*
Mobile No
Age
*
Gender
*
Male
Female
Migraine Assessment
Headache worse in the morning on waking?
Yes
No
Headache increases and decreases with the rising of the sun?
Yes
No
Headache worse in the afternoon & evening?
Yes
No
Headache worse at night?
Yes
No
Headache worse after consuming alcohol?
Yes
No
Headache alternating with backache?
Yes
No
Headache worse from anger?
Yes
No
Headache worse when climbing stairs?
Yes
No
Headache better from tight bandage (pressure)?
Yes
No
Headache worse from exhaustive mental labor?
Yes
No
Headache worse from drinking beer?
Yes
No
Blurred vision or flickering before headache?
Yes
No
Headache from overworking in business?
Yes
No
Headache worse from cold exposure?
Yes
No
Headache worse from constipation?
Yes
No
Headache worse from coughing?
Yes
No
Headache worse from dancing?
Yes
No
Headache better in darkness?
Yes
No
Headache worse after eating or overeating?
Yes
No
Headache worse from an empty stomach?
Yes
No
Headache better after eating?
Yes
No
Headache worse from depression?
Yes
No
Headache better after nosebleed?
Yes
No
Headache worse from excitement?
Yes
No
Headache worse from eye strain?
Yes
No
Headache worse after eating fruits?
Yes
No
Headache worse from heat?
Yes
No
Headache better from heat?
Yes
No
Headache due to gastric issues?
Yes
No
Headache worse from grief?
Yes
No
Headache after heavy bleeding?
Yes
No
Headache associated with piles?
Yes
No
One-sided headache?
Yes
No
Right-sided headache?
Yes
No
Left-sided headache?
Yes
No
Headache starting at the back and moving forward?
Yes
No
Hysterical headache?
Yes
No
Headache that gradually increases and decreases?
Yes
No
Headache worse from bending or stooping?
Yes
No
Headache worse from sudden movements?
Yes
No
Headache worse from bright light?
Yes
No
Headache alternating with backache?
Yes
No
Headache worse from lying down?
Yes
No
Headache worse after masturbation?
Yes
No
Headache worse before menstruation?
Yes
No
Headache worse during menstruation?
Yes
No
Headache improves when period starts?
Yes
No
Headache in place of menstruation?
Yes
No
Headache after a missed period?
Yes
No
Headache from emotional distress?
Yes
No
Headache from mental exertion?
Yes
No
Headache from motion?
Yes
No
Headache from moving head?
Yes
No
Headache from music?
Yes
No
Nervous headache?
Yes
No
Headache from noise?
Yes
No
Headache in the nape of the neck?
Yes
No
Headache paroxysmal (sudden and intense)?
Yes
No
Headache periodic?
Yes
No
Headache better from sweating?
Yes
No
Headache worse from pressure?
Yes
No
Headache better from pressure?
Yes
No
Headache pulsating?
Yes
No
Headache better from rest?
Yes
No
Headache from train or boat journey?
Yes
No
Headache in school-going girls?
Yes
No
Headache from sexual excess?
Yes
No
Chronic headache after serious illness?
Yes
No
Headache every morning with severe nausea at noon?
Yes
No
Headache after sleep, fear of sleeping?
Yes
No
Headache from smoking?
Yes
No
Headache starting from the cervical spine?
Yes
No
Headache worse from stooping?
Yes
No
Headache in fast-growing students?
Yes
No
Headache during summer?
Yes
No
Headache due to sun exposure?
Yes
No
Headache after drinking tea?
Yes
No
Headache common in teachers?
Yes
No
Headache from excessive mental activity?
Yes
No
Headache better after urination?
Yes
No
Forehead headache?
Yes
No
Headache in the occipital region (back of head)?
Yes
No
Headache moving from the back of the head to the right eye?
Yes
No
Headache moving from the back of the head to the left eye?
Yes
No
Headache moving from the back of the head to the forehead?
Yes
No
Headache after suppressed nasal discharge?
Yes
No
Headache during menopause?
Yes
No
Headache associated with nausea or vomiting?
Yes
No
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