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Migraine Conversation Guide

Having to live with chronic pain is difficult enough without the added burden of migraine headaches.
This guide will help you to have a meaningful conversation with your health care provider. Use this tool
before you go to your next appointment.

Pain level

0 1 2 3 4 5 6 7 8 9 10
None Extreme

Age onset

10-20 20-30 30-40 40-50 50-60 60-70+


Young Later in life

Frequency of headaches per month

0 1 2 3 4 5 6 7 8 9 10
None 10 or more

ASSOCIATED SYMPTOMS
Any associated with aura

0 1 2 3 4 5 6 7 8 9 10
None All the time

Nausea

0 1 2 3 4 5 6 7 8 9 10
None Severe nausea

Sweating

0 1 2 3 4 5 6 7 8 9 10
None Sweating

Copyright: 2015 The American Chronic Pain Association 800.533.3231 www.theacpa.org Supported by a grant from 1
Migraine Conversation Guide

Blood shot eyes

0 1 2 3 4 5 6 7 8 9 10
None Severely blood shot

Sensitivity to light

0 1 2 3 4 5 6 7 8 9 10
None Extremely sensitive

Sensitivity to sound

0 1 2 3 4 5 6 7 8 9 10
None Extreme sensitivity

Smells

0 1 2 3 4 5 6 7 8 9 10
None Extreme sensitivity

Mood changes

0 1 2 3 4 5 6 7 8 9 10
None Extreme mood swings

Congestion

0 1 2 3 4 5 6 7 8 9 10
None Severe congestion

Copyright: 2015 The American Chronic Pain Association 800.533.3231 www.theacpa.org Supported by a grant from 2
Migraine Conversation Guide

Sleep Disturbance

0 1 2 3 4 5 6 7 8 9 10
None Severe insomnia

TRIGGERS OR MAKES PAIN WORSE


Alcohol Food Activity Body Positions Noises

Yes Yes Yes Yes Yes


No No No No No

Weather Stress

Cold Stormy Dry Yes


Hot Wet Other (specify) _______________________ No

Chewing Coffee Environment/smells Hormone changes

Yes Yes Yes Yes


No No No No

OTHER TRIGGERS (please list)

Copyright: 2015 The American Chronic Pain Association 800.533.3231 www.theacpa.org Supported by a grant from 3
Migraine Conversation Guide

What Makes Pain Better (check all that apply)


Ice Darkness Medication
Heat Quiet Sleep

Treatments Tried (please list)

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Copyright: 2015 The American Chronic Pain Association 800.533.3231 www.theacpa.org Supported by a grant from 4

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