Date:

Date:

Date:

Date:

Warning Signs:

Warning Signs:

Warning Signs:

Warning Signs:

Time Begun:

Time Begun:

Time Begun:

Time Begun:

Time Ended:

Time Ended:

Time Ended:

Time Ended:

Type of Pain: (e.g., piercing, throbbing, etc.)

Type of Pain: (e.g., piercing, throbbing, etc.)

Type of Pain: (e.g., piercing, throbbing, etc.)

Type of Pain: (e.g., piercing, throbbing, etc.)

Intensity of Pain: (circle one)

(L) 1 2 3 4 5 6 7 8 9 (H)

Intensity of Pain: (circle one)

(L) 1 2 3 4 5 6 7 8 9 (H)

Intensity of Pain: (circle one)

(L) 1 2 3 4 5 6 7 8 9 (H)

Intensity of Pain: (circle one)

(L) 1 2 3 4 5 6 7 8 9 (H)

Location: (e.g., between eyes, back of head, etc.)

Location: (e.g., between eyes, back of head, etc.)

Location: (e.g., between eyes, back of head, etc.)

Location: (e.g., between eyes, back of head, etc.)

Treatment or Medication Taken:

Treatment or Medication Taken:

Treatment or Medication Taken:

Treatment or Medication Taken:

Effect of Treatment:

Effect of Treatment:

Effect of Treatment:

Effect of Treatment:

Hours of Sleep:

Hours of Sleep:

Hours of Sleep:

Hours of Sleep:

What I Ate Today:

What I Ate Today:

What I Ate Today:

What I Ate Today:

Events Prior to Headache: (e.g., strenous activity, elevated stress, etc.)

Events Prior to Headache: (e.g., strenous activity, elevated stress, etc.)

Events Prior to Headache: (e.g., strenous activity, elevated stress, etc.)

Events Prior to Headache: (e.g., strenous activity, elevated stress, etc.)

Comments:

Comments:

Comments:

Comments: