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Headache Questionnaire: Are Your Migraines Severe?

Headaches are not normal and this is one of the myths surrounding headaches. Take this free headache questionnaire to see what is the severity of your migraines.

1.How many days in the last 3 months did you miss work due to headaches?

____________

2.How many days in the last 3 months did you have reduced productivity at work due to headaches? (do not count the days from question one)

____________

3. How many days in the last 3 months were you not able to do housework (repairs, cleaning, cooking etc) due to your headaches?

____________

4. How many days in the last 3 months did you have reduced productivity with household work due to your headaches?(do not count the days in question 3)

____________

5. How many days in the last 3 months did you miss family, social, or leisure activities due to your headaches?

____________

Total Number of Days = ____________

GradeDefinitionScore
ILittle Disability0-5
IIMild6-10
IIIModerate11-20
IVSevere20+



Print this out and take it to your healthcare provider.
Your responses to this headache questionnaire will help your provider define your care.

Read more about different types of headaches.

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