Cluster Headache Questionnaire

Headache Questionnaire

This form doesn't store any data - fill it out and generate a PDF report that you can take to your doctor's appointment. This is not a tool for diagnosis but having these details can help your doctor.

Headache Questionnaire

Generated on: 3/1/2026

1. How long have you suffered these headaches?

2. What is the frequency of attacks? i.e., how many times do you have them in a week, month, or a year

3. Of your last 10 attacks, how many commenced while you were asleep?

4. Which part of your head hurts during an attack?

5. How would you describe the quality of the pain? For example, throbbing like a heartbeat, boring or piercing, pressure-like burning or stabbing

6. In association with your attacks, do you develop any of the following?

Visual shimmeringNauseaNumbness/tinglingVomitingGlare/light sensitivityNoise sensitivityBlockage of a nostrilTearing from your eye/s

7. Do you have a recognisable warning that a headache is about to occur? For example, sweet craving, hunger, excessive yawning, an abnormal sense of well-being, excessive noise sensitivity or irritability, signs of fluid retention, i.e., tightening rings on your fingers or ankle swelling.

8. How disabled are you when you experience a headache?

I can continue with normal activitiesNormal activities are restricted but not preventedI am disabled and bed-bound

9. Are you aware of any triggering or aggravating factors such as physical exertion, stress, coughing, stooping, straining, menstruation, the ingestion of alcohol or foodstuffs?

10. Are you aware of any alleviating factors? For example, bed-rest, avoidance of glare and noise, specific medications or physical interventions such as massage, application of heat/cold pack.

11. Take with you a listing of all medications you have tried in an attempt to control your headaches in the past, preferably with: • an indication of the dosages used; • the duration of the therapy; and • the outcome.

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