Recording a headache diary

Headache triggers vary and may be related to dietary habits, different foods, activity, and environmental factors

Helping your patient to identify factors that contribute to their headaches might help reduce the severity and frequency of their headaches.

This may sound easy, and 90% of patients can identify one trigger, but 83% of patients have multiple triggers. It has also been shown that sometimes a trigger will provoke a migraine, while at other times it may not. In other cases, more than one trigger must be present to provoke a migraine.

To identify triggers, it is helpful to have a way to analyze factors that may contribute to developing headaches. A headache diary is one such tool. There are several options available for patients to record headache diary data. These include phone apps, computer-based records, printed diaries, or simple calendars. However, a diary is only useful if it is used diligently and reviewed together. This article will help you teach your patients how to maintain a headache diary.

What should be included in a headache diary?

Frequency of headache attacks

It’s important for patients to track the number of headache attacks. Frequency of occurrence is one criterion used in the International Headache Society diagnostic schema. The frequency of attacks is the usual characteristic that helps you determine the need for interventional treatments. Studies have show that the use of a diary increases the accuracy of determining frequency.

Interventions attempted

What about their attempts to alleviate their headache pain? Have their interventions reduced the severity or frequency of their headaches? A diary can be highly informative in assessing the efficacy of specific interventions. Many times, a patient will report that nothing has changed after an intervention. But, with the review of a well-kept diary, you may uncover a trend toward reduced severity, an increased response to rescue drugs, or subtle changes in frequency. These trends can be used to refine treatment.

Potential triggers

Has your patient noticed anything that seems to trigger their headaches? The six to eight hours before the attack are particularly important to record. Have your patients record as many aspects of daily life as possible, such as: what they may have eaten, missed or delayed meals, medications taken (including vitamins or other products), how much they have slept, and any exercise. Have them record social or work activities and factors such as the weather. Female patients should also record details of their menstrual cycles. When a patient is taught to watch for triggers that may cause a headache, they are aiding in the analysis and treatment of their headaches.

Potential preventative measures

Make sure your patients record the events on their headache free days too! In the same way, instruct your patients to pay attention to shifts in actions, medications, behaviours or mood, and environment which may be positively impacting their headache frequency and severity. Some actions on headache-free days could potentially prevent headaches!

Emotional states headaches

Stress and headaches

A patient’s stress and emotional state has been implicated in all primary headaches. If the patient is aware of possible triggers for their stress levels, it can be helpful for treating the events. Stress is listed most often by migraine sufferers as a trigger for their attacks. Stress might precipitate migraines in those who are predisposed to the disorder and may also contribute to migraines becoming chronic.

Neuroendocrine factors are believed to be responsible for stress. The physiology of the stress response involves the release of corticotrophin releasing hormone (CRH) in concert with other psychological responses to stressors.

Depression and headaches

Depression is known to occur in patients with increased migraine frequency. However, a direct link is not well established. There is indirect evidence that the two conditions may share features. For instance, antidepressants are frequently used to treat headache.

This is an edited excerpt from the Medmastery course Headache Masterclass by Robert Coni, DO, EdS, FAAN. Acknowledgement and attribution to Medmastery for providing course transcripts.


Neurology Library: Headache – History, Examination and Investigation

Neurology Library

LITFL author Robert Coni DO EdS

Robert Coni, DO, EdS, FAAN. Vascular neurologist and neurohospitalist and Neurology Subspecialty Coordinator at the Grand Strand Medical Center in South Carolina. Former neuroscience curriculum coordinator at St. Luke’s / Temple Medical School and fellow of the American Academy of Neurology. In my spare time, I like to play guitar and go fly fishing. | Medmastery | Linkedin |

Dr Hannah Bone LITFL Author

BMBS (The University of Nottingham) BMedSci (The University of Nottingham). Emergency Medicine RMO at Sir Charles Gairdner Hospital Perth, WA. Interested in Medical Education and Emergency Medicine. Swimmer and frequent concert attendee.

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