CHILDHOOD HEADACHE
INVESTIGATING THE CAUSE
An investigation to determine the cause of your child's headaches may be extensive and include several laboratory studies as well as a complete physical examination. Even so, perhaps the most important part of the investigation will be collecting detailed information regarding several factors. You can help this part a great deal if you will complete a copy of the following questionnaire and share the information with your physician.
DESCRIPTION OF PAIN
1. At what age did the headaches begin?
2. Where is the headache located? (front, side, top, back of neck, all over?)
3. Does the pain begin in one area and spread to a different area? ____ Yes ____ No
If so, where?
4. How severe is the pain? Does it awaken the child from sleep, interfere with school
work, sports, TV?
5. What is the nature of the pain? Pressure, band around the head, throbbing, ache?
6. Are there any symptoms occurring before the headache? ____ Yes ____ No
If yes, specify:
____ Light sensitivity ____ Irritability
____ Mood changes
____ "Tightening up" and "relaxing" movements
____ Weakness ____ Unusual odors
____ Spots before eyes ____ Others
7. How often does the headache occur?
8. How long does it last?
Minutes ____ Hours ____ Days ____ Weeks ____
9. When does it occur?
____ Mornings ____ At night ____ Before meals
____ On weekdays ____ On vacation ____ Evening
____ On weekends ____ During school ____ While reading
____ On holidays ____ Afternoon
FAMILY HISTORY
1. Does anyone else in the family have headaches? ____ Yes ____ No
2. Type of headaches: Migraine ____ Tension ____ Other
3. Relationship to patient:
4. History of allergy in family? ____ Yes ____ No
5. Does any member of the family have diseases involving the head?
____ Yes ____ No If yes, specify: ____Tumor ____Stroke ____Other
MENTAL STATUS
(Check those that apply.)
____ Acts normal during attack
____ Acts differently during attack
____ After headache, drowsiness or sleep
____ Other <
FACTORS INFLUENCING HEADACHE(Check those that apply.)
1. Caused by:
____ Movies, TV, sunlight, strobe lights
____ Coughing or sneezing
____ Anxiety and stress (exams, arguments, illness, exercise, allergy)
____ Temperature change
____ Recent head injury
____ Reading
____ Changes in position
____ Other
2. Relieved by:
____ Non-prescription pain medicine ____ Sleep/bed rest
(name/dosage) ____ Other (cold compresses)
____ Distraction ____ Other (drugs--name them)
____ Quiet/darkened room
ASSOCIATED SYMPTOMS
(Check those that apply.)
____ Abdominal pain ____ Chills
____ Pallor, blueness, flushing ____ Fatigue
____ Sweating ____ Sinus pain
____ Dizziness (vertigo) ____ Fever
____ Nausea/vomiting ____ Change in sense of smell
____ Neck or shoulder soreness
____ Hearing loss/ringing in ears
____ Double or blurred vision ____ Weakness
____ Numbness ____ Other
____ Stuffy or runny nose
PHYSICAL HISTORY
(Check those that apply.)
____ Loss of appetite ____ Weakness
____ Fatigue or tiredness ____ Drugs
____ Abdominal pain when younger ____ Allergies
____ Burning or tearing of eyes ____ Behavior change
____ Teeth clenching or grinding ____ Seeing double
____ Recent dental work ____ Birth injury
____ Unexplained fevers ____ Nightmares/phobias
____ Staggering ____ Runny nose
____ Nervous tremor ____ Head trauma
____ Seizures
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