HEADACHE SURGERY INFORMATION PACKET
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1 HEADACHE SURGERY INFORMATION PACKET Inside this packet, you will find a brochure containing important information about several possible sites for nerve decompression surgery. Please read this information before you begin to fill out the paperwork. Each patient has a different combination of sites for migraine surgery and our team relies on the information you provide to make the best surgical decision for you, so please be specific when completing the paperwork in this packet. Step 1: Fill out the Headache Questionnaire Use the headache log to help you report the specific information about your headaches. You may even begin to see a pattern about your headaches that you did not realize before. Please use this form to provide additional information that you could not put on the headache log. Step 2: Fill out the Headache Disability Questionnaire Please be specific about any health issues you may have other than your headaches. Provide a list of the prescription and non-prescription medications you are taking. It does help if we know the dosages and how often you take the medications. Step 3: Fill out the Functional Nose form You and your family/friends can work together to help you complete this form. Pay attention to your body and daily functions in order to best answer these questions. For example, you may not have noticed that you breathe through your mouth instead of your nose. Once you have completed the paperwork, please fax/ /mail the information to our office: Knoxville Plastic & Craniofacial Surgery 9239 Park West Blvd, Suite 202 Knoxville, TN 3723 Fax: info@drjasonhall.com *If a CT scan has been advised, please bring the disc with you to your appointment* Page 1 of 5
2 HEADACHE HISTORY FORM Patient Name: Date:_ Who is your current treating physician? How many headaches do you experience per month on average? How painful are is your average headache? (circle one number) Mild Severe How long do your headaches usually last? When do your headaches usually start? (circle one) Morning Afternoon Evening Night Where are your headaches usually located? (circle all that apply) behind right eye behind left eye behind both eyes right temple left temple both temples above right eyebrow above left eyebrow above both eyebrows back of head on right back of head on left back of head both sides How old were you when your headaches started? Page 2 of 5
3 How would you describe your headaches? (circle all that apply) throbbing/pounding ache/pressure like a tight band other (please describe): Do your headaches awaken you at night? (check one) never occasionally often Do any of the following occur before/during your headaches? (circle all that apply) nausea/vomiting runny nose bothered by light/noise blurry/double vision flashing/colored lights puffy/droopy eyelids other Do any of the following bring on your headaches or make them worse? stress bright lights weather changes loud noise(s) heavy lifting fatigue exercise other Do any of the following make your headaches better? (circle all that apply) rest exercise quiet/darkness pressure on head massage vomiting hot or cold compresses other Page 3 of 5
4 Do you have any areas that are tender either before, during, or after a headache? (circle all that apply) above the eyebrows the temple in front or behind the ears the back of the neck the bridge of the nose Does pressure or massage on the following areas reduce or eliminate the headache pain? (circle all that apply) above the eyebrows the temple in front of or behind the ears the back of the neck the bridge of the nose If you are female, do your headaches change with any of the following? menstrual periods/pregnancy birth control pills/ other hormones Have you ever had a head or a neck injury requiring medical treatment? no yes If yes, describe Have you had your headaches evaluated by a neurologist? no yes If yes, by whom and when What was the diagnosis? (check all that apply) migraine tension-type cluster occipital neuralgia other (specify) Page 4 of 5
5 List all past tests you had for your headaches: List all past headache treatment(s) and medications: List all current headache medications: To what extent do your headaches affect your quality of life? (check one) extremely moderately very little none at all What activities in life have you given up because of your headaches? Page 5 of 5
6 The Migraine Disability Assessment Test The MIDAS (Migraine Disability Assessment) questionnaire was put together to help you measure the impact your headaches have on your life. The information on this questionnaire is also helpful for your primary care provider to determine the level of pain and disability caused by your headaches and to find the best treatment for you. INSTRUCTIONS Please answer the following questions about ALL of the headaches you have had over the last 3 months. Select your answer in the box next to each question. Select zero if you did not have the activity in the last 3 months. 1. On how many days in the last 3 months did you miss work or school because of your headaches? 2. How many days in the last 3 months was your productivity at work or school reduced by half or more because of your headaches? (Do not include days you counted in question 1 where you missed work or school.) 3. On how many days in the last 3 months did you not do household work (such as housework, home repairs and maintenance, shopping, caring for children and relatives) because of your headaches? 4. How many days in the last 3 months was your productivity in household work reduced by half of more because of your headaches? (Do not include days you counted in question 3 where you did not do household work.) 5. On how many days in the last 3 months did you miss family, social or leisure activities because of your headaches? Total (Questions 1-5) A. On how many days in the last 3 months did you have a headache? (If a headache lasted more than 1 day, count each day.) B. On a scale of 0-10, on average how painful were these headaches? (where 0 = no pain at all, and 10 = pain as bad as it can be.) Scoring: After you have filled out this questionnaire, add the total number of days from questions 1-5 (ignore A and B) MIDAS Grade Definition MIDAS Score I Little or no disability 0-5 II Mild disability 6-10 III Moderate disability IV Severe disability 21+ Please give the completed form to your clinician. This survey was developed by Richard B. Lipton, MD, Professor of Neurology, Albert Einstein College of Medicine, New York, NY, and Walter F. Stewart, MPH, PhD, Associate Professor of Epidemiology, Johns Hopkins University, Baltimore, MD.
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