This short questionnaire may help you to identifiy some of the causes for your headaches.
 
1

Do you have any ideas concerning the origin of your headaches ? (diabetis, hypertension , eye problems ,etc.)

Yes No
2 Do you always have the same kind of headache ?

 Yes No
3 Do you have more than one kind of headaches ?

 Yes No
4 Is your headache sometimes so intense that it becomes unbearable ?

 Yes No
5

Does your headaches occur during stress episodes or tense moments at home, at work or during social events ?

 Yes No
6 Are your neck, your shoulder and neck muscles hard and sensitive during your headaches ?

 Yes No
7 Does your headache last for long, with no relapse, like a constant pressure ?

 Yes No
8 Does you headache feel like a hair band wich would be far too tight ?

 Yes No
9 Do you have a headache more often than once a week ?

 Yes No
10 Does your headache occur during the day ?

 Yes No
11

Is there someone in your family (mother, father or other relative) who has headaches like yours ?

 Yes No
12 Do physical activities (running, training, sexual activity) affect your headaches ?

 Yes No
13 Do you have nauseas and/or sickness before or during your headaches ?

 Yes No
14 Do you experience visual troubles (flashes, sensitivity to light, sparkles, troubled vision etc) during or after your headaches ?

 Yes No
15 Does your headache usually start on one side of your head ?

 Yes No
16 Do you have the feeling that your headache resonates with your heartbeat ?

 Yes No
17 Do you experience headaches most often when waking
up ?

 Yes No
18 Do you experience headache mostly during week-ends or at the beginning of holidays ?

 Yes No
19 (women only) Are your headaches associated with your periods ?

 Yes No
20 When you have a headache, is the eye on the painful side more subject to tears ?

 Yes No
21 Does alcohol provoke or reinforce your headaches ?

 Yes No
22 Do chocolate, cheese, milk, peanuts, chinese food or any other food factor provoke or reinforce your headaches ?

 Yes No
23 Do you have hearing troubles : noises, buzzing, or other, before or during your headaches ?

 Yes No
24 Have you noticed nervous troubles, muscular weaknesses or other differences during your headaches ?

 Yes No
25 Do you have facial or maxillary pain, or blocked or congestioned sinuses during your headaches ?

 Yes No
26 When was your last visit to the dentist ? More than 18 months ago ?

 Yes No
27 Have you had exams prescribed for your headaches (radiographies, scanner, other) ?

 Yes No
28 Have you tried preventive treatments for your headaches ? Try to list them.

 Yes No