Headache History Questionnaire
(scroll down for rationale for each question)
(click here for a printable .pdf version)
1. On a scale of 1-10, with "10" being the worst pain imaginable above the shoulders, how many
    mornings per week do you wake with a "0" (zero)?		 ____
2.  On a scale of 1-10, what's the average "number" you usually wake with? ____
3.  What % of your waking time do you have some degree of headache? ____
4.  What % of your waking time do you have a "0" (zero) without taking medications? ____
5.  What is your average headache pain level (1-10 scale) throughout the day? ____
6.  On a scale of 1-10, what is the worst pain level you experience? ____
7.  What time of day do you usually experience your worst headaches? ____
8.  How many times per week (or month) might you experience your worst pain? ____
9.  Where does your pain seem to originate from?
     ___________________________________________________________________________
10.  How would you describe your pain? 
     (examples: throbbing, squeezing, pressure, dull, stabbing, shooting, etc.)
     ___________________________________________________________________________
11.  Please circle the types of health care providers you've seen for your headaches.
      MD    Neurologist    ENT    Internist    Physical Therapist    Chiropractor   Dentist 
      Others: _____________________________________________________
12.  What medical tests have been performed regarding your headaches?
       CT scan    MRI    Xray    Blood analysis    Other: ________________________
13.  What types of procedures or treatments (including dental) have you had 
       regarding your headaches?
       ___________________________________________________________________________
14.  What medication(s) do you now take to prevent your headaches?
       _________________________________________________________________
15.  What medications have you tried to prevent your headaches?
     _________________________________________________________________
16.  What prescription or over-the-counter medications do you take 
        to relieve you headaches?   (and how much) 
        _________________________________________________________________
Shade in the areas below where you experience you discomfort


 
Rationale for questions

1-5.  The goal is to confirm a "foundation" for the headaches.  There is nothing normal about waking with any degree of discomfort, although a majority of chronic headache suffers accept a tolerable degree of discomfort as acceptable and unremarkable.  They have succumbed to the regular pain, and report only their most intolerable pain.

6. This is what the patient is most concerned with, and what previous treatments have been aimed at.  Confirm with the patient that this too is your goal, but to prevent the worst pain the causative and perpetuating activity that creates the "foundation" is necessary. 

7.  The patients who have severe afternoon episodes usually have more muscular parafunction throughout the day.  Although the answer may be "sometime in the afternoon" (and therefore the patient's focus), they still have discomfort at other times of the day.  Those who report more severe afternoon episodes have a greater necessity for a "Daytime" device.  Patients reporting the most severe episodes upon waking or in the morning (some will report they are awakened from sleep) may have less of a necessity for a daytime device.

8.  This is usually what they report to a physician, and may have been interpreted as how many headaches per week (or month) they have, when it simply indicates how intense their (nearly) on-going discomfort can get.
For example, if the response was "5 times per month", you might reply: "If your worst headache lasts for two days, then that takes up 10 days per month.  So then, does that mean you  have a "zero" the other 20 days per month?"

9.  The position of the mandible during the muscular parafunction events dictates the origin of the discomfort. Examples--  Bilateral temporal pain: centric clenching;   Unilateral temporal: unilateral clenching;    Frontal (sinus) with neck symptoms: protrusive clenching;   Facial and TMJ: excursive clenching... or alternating combinations.

10.  This is a rule out type of question.  Terms which DO NOT comply with myofascial pain (examples: shocking, jolting, knife-like) should be further investigated by a physician.

11-15.  Just to confirm that you are NOT the first provider that the patient has consulted with regarding their headaches.  If you are, and the patient has been having the headaches for less than one year, insist they see their physician for a complete work-up.  If it has been more than one year, note in the chart that you recommend a full medical work-up.

14-16.  Do not recommend that the patient change any of their medications.  Note that most preventive medications are taken before bed. 

As you review the questionnaire responses and listen to their comments, imagine if what they describe could be caused and/or perpetuated highly intense nocturnal clenching, and what type of clenching activity might be required to relate to their responses.  There is nothing normal about the activities you'll be imagining... if fact, you might think, "That would be pretty weird if they were to do that...", which is exactly the point.  The patient in front of you has most likely been given a clean bill of health, yet they are miserable.  What they are doing must be pretty weird from them to be where they are.

Also, the patient may tell you things that they think you want to (or might need to) know.  They may provide what they think are insights or suggestions. Something to consider always:  Imagine the patient has been "possessed" by the muscular parafunction animal.  Sometimes, "the animal" is speaking to you through the patient.  It is trying to mislead you.  It does not want to be disturbed.  For example, the patient might say:  "I feel that my bite is off", or, "I can't find a place where my teeth are supposed to come together".  The animal is trying to convince you that you should improve the occlusal scheme.  Why?  Because that would make the animal a better clencher.  At this moment, remind the patient: "You see!  'The Condition' is talking to us!  It wants to keep on with its activity.  Why would you comment that your 'bite' was off or needed to be improved if you weren't biting frequently?"