Table 6 Migraine headache questionnaire form

Subject number:

Name:

Class:

Age:

Gender:

Female

Male

Marital status:

Single

Married

Family type:

Nuclear

Extended

Other

Socioeconomic status:

Lower

Middle

Upper

Headache history in family:

Yes

No

History of neurological disease in family:

Yes

No

Your systemic disease:

Yes

No

Your psychiatric disease:

Yes

No

Smoking habits:

Yes

No

Alcohol use:

Yes

No

Have you ever had five or more headache unrelated to any other illness during the last 6 months?

Yes

No

Headache characteristics:

Throbbing

Burning

Pressing

Localization:

Unilateral

Bilateral

Mean duration of headache:

Associate symptoms:

Nausea

Vomiting

Photophobia

Phonophobia

Pain intensity:

Mild

Moderate

Severe

Aggravation by or causing avoidance of physical activity:

Yes

No