1. On how many days in the last 3 months did you miss work or school because of your headaches?

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1 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 or 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+ Page 1 of 8

2 TO ALL HEADACHE PATIENTS: We would appreciate your cooperation in filling out parts I and II of this form. In our evaluation of headache, your history is typically our most valuable tool for diagnosis and subsequent treatment. If you have any questions regarding this form, please ask. Part I: Patient History A. Identification 1. Name: 2. Age: 3. Sex: 4. How were you referred to the Headache office? (Name, address, fax, and phone number of referring physician, if known; if not referred by a physician, write self ) B. Headache History 1. How old were you when you first began to have headaches bad enough to interfere with your normal daily activities? _ 2. Has there been any recent changes in your headaches? YES NO If you answered yes, please specify what type of change: 3. Within the past 30 days, how many were you entirely headache-free? 4. Do you have daily headaches? YES NO. If yes, how long have you had daily headaches? < 6 months > 6 months If longer than 6 months, please specify how long. _ 5. If you are having daily headaches, are you now ever completely free of head pain? YES NO Page 2 of 8

3 6. How long do your worst headache attacks last? a) 0-1 hr b) > 1-3hr c) 4-12 hr d) >12-24 hr e) >24-48 hr f) >48-72 hr g) >72 hr h) constant i) too variable j) unknown 7. Check any of the following factors which seem to trigger a headache attack in you: alcohol (specific types ) certain foods (specify types ) menstruation emotional stress odors (please list: ) too much or too little sleep missing meals other (please specify: ) [MD: MRM yes no] [MD: If yes for MRM, pure? yes no] [MD: If yes for MRM, same longer SM more severe more Rx refractory] 8. How many days within the last 30 did you have any kind of headache (mild, moderate, or severe)? 9. Are your headaches ever incapacitating (e.g., have to leave work or school or lie down undisturbed)? yes no 10. How many days within the last 30 were you incapacitated by headache and unable to carry out your routine activities for at least one hour? [MD: F/S/ profile MIDAS Score ] 11. With your most severe headaches, does physical activity worsen the pain? yes no 12. Is your headache pain ever throbbing? yes no 13. Is your headache ever localized to one side of the head? yes no If yes, is your headache always on the same side? yes no If yes, which side? right left 14. Do your headaches ever seem to arise from your neck? yes no [MD: cervicogenic? yes What %? [MD: Lateralized? yes (describe ) no] Page 3 of 8

4 15. Describe your typical headache; what is the pain like and where it is located? 16. Do you ever experience any of the following symptoms in association with your headache attacks (before, during, or after)? Please check the appropriate boxes: eye tearing nasal congestion nausea vomiting visual changes (visual distortion, flash cubes, zig zags, blind spots, sparkles, etc). (please describe: ) numbness or tingling in the face, arm, or leg. Describe: inability to tolerate bright light (photophobia) sensitivity to sound [MD: visual aura sensory aura other aura What? ] C. Medical History 1. Please check the following items that pertain to you and your medical history: Hypertension (high blood pressure) Heart disease (please describe ) Diabetes Significant head injury (if yes, was it within the past 6 months? yes no; Describe: ) Kidney stones Sleep apnea Panic attacks Cigarette smoking (# of cigarettes per day ) Alcoholic beverage consumption Drug allergies (please list: ) Treated for depression in the past with counseling, medication, or both 2. Please list any other significant medical condition or psychiatric problems not listed above for which you are under the care of another physician. 3. Please list all medications you are presently taking, including over-the-counter medications and birth control pills. _ [MD: MOH? yes no (if yes, drug(s) & use/freq ] Page 4 of 8

5 4. If you are a female and potentially able to become pregnant, are you practicing birth control? yes no (if yes, what method? ) 5. If you are female, have you had a hysterectomy? yes no If yes, what year? If yes, were the ovaries both removed? yes no unknown 6. [MD: BMI ] 7. Have you ever had a spinal tap? yes no unknown 8. Have you ever been admitted to the hospital because of your headaches? yes no If yes, how many times within the past 12 months? 9. Have you ever been to an emergency room for treatment of headache? yes no If yes, how many times within the past 12 months? 10. Have you ever had a brain scan in the past? yes no unknown If yes, what type? CT MRI Both Unknown Where and when was the most recent scan performed? _ D. Family History 1. Has anyone in your family had a significant problem with headaches or has been diagnosed as having migraine or sick headaches? yes no unknown If yes, who? E. Social History 1. What is your occupation? 2. If you are employed, approximately how many days of work did you miss because of headache within the past year? 3. Are you medically disabled and receiving disability payments? yes no If yes, what is the reason for your disability? _ If yes, for how many years have you been disabled? 4. Are you married divorced widowed single? 5. Do you have children? yes no If yes, how many? gender and ages Page 5 of 8

6 6. What is the highest level of education you ve completed? F. Review of Systems 1. Are you currently having difficulties with your sleeping (insomnia, early morning awakening, always sleepy, etc)? yes no If yes, please describe: [MD: DFA MNA other ] 2. Are you currently depressed? yes no If yes, is your depression mild moderate severe? 3. Are you chronically anxious? yes no 4. Are you currently receiving formal treatment (counseling and/or medications) for anxiety or depression? yes no If yes, please describe what type of treatment you are receiving: G. Other 1. Is there anything else you think is important for your doctor to know? PHYSICIAN ONLY: Diagnosis: a) episodic migraine b) chronic migraine c) NDPH w/mf d) cluster ( cyclical 1 chronic 2 chronic ) e) ETTH f) CTTH g) prolonged aura h) migrainous infarction i) post-traumatic migrainous headache j) other (specify: ) k) multiple (as checked above) Page 6 of 8

7 Part II: Medication History Please complete the following two charts. ONLY FILL IN INFORMATION FOR DRUGS YOU HAVE USED IN THE PAST. Drug name Topamax THERAPIES TRIED FOR HEADACHE PREVENTION Maximum Dose Achieved (if known) How long did you take it? Did it help you? List side effects, if any. Why did you stop? Depakote Elavil (amitriptyline) Pamelor (nortriptyline) Inderal (propranolol) Zonegran (zonisamide) Botox injections Occiputal nerve blocks Verapamil (Calan, Verelan) Other Other MEDICATIONS TRIED FOR ACUTE HEADACHE TREATMENT Page 7 of 8

8 Drug Name Oral Imitrex (sumatriptan) Injectable Imitrex For how long did you use it? Why did you stop it? List side effects, if any. Did it help you? Treximet Maxalt Oral Zomig Intranasal Zomig Relpax Axert Frova Amerge DHE nasal spray (Migranal) Injectable DHE Opioid or narcotic (names: ) Indomethacin (Indocin) Naproxen sodium (Aleve) Oral steroid (ex: prednisone) Other Page 8 of 8