What information should be recorded in a headache diary?

What Information Should Be Recorded in a Headache Diary

A headache diary should document the pattern and frequency of headaches, accompanying symptoms (nausea, photophobia, phonophobia), pain characteristics (severity, duration, location, quality), and all acute medication use. 1

Core Elements to Record Daily

Pain Characteristics

• Frequency of headache episodes – document every headache day, as patients often underreport milder headache days 1, 2
• Duration of each episode – record start and end times to capture whether attacks last 4-72 hours (migraine range) or have different patterns 1
• Pain severity – use a numerical scale to quantify intensity, as this correlates with disability and treatment response 1
• Pain location – note whether unilateral or bilateral, as this distinguishes migraine from tension-type headache 1
• Pain quality – describe as pulsating, pressing, or tightening to aid diagnosis 1

Associated Symptoms

• Nausea and vomiting – these are cardinal migraine features that may be underreported at clinical interviews compared to diary entries 1, 3
• Photophobia (light sensitivity) – record presence or absence, as this is highly specific for migraine 1, 4
• Phonophobia (sound sensitivity) – document separately from photophobia, as both together strongly suggest migraine 1, 4
• Aura symptoms – if present, note the type (visual, sensory, speech), duration, and whether symptoms spread gradually over ≥5 minutes 1

Medication Tracking

• All acute medication use – record every dose of pain relievers, triptans, or other abortive medications to identify medication-overuse patterns 1
• Preventive medication adherence – document daily preventive medication use if prescribed 1
• Response to treatment – note whether medication provided relief and how quickly 1
• Adverse effects from medications – track side effects to guide treatment adjustments 1

Additional Important Elements

Disability and Functional Impact

• Degree of disability – record whether the headache prevented work, household tasks, or social activities 1
• Aggravating factors – note if routine physical activity worsens the headache, as this distinguishes migraine from tension-type headache 1
• Relieving factors – document what helps (rest, dark room, lying flat) 1

Trigger Identification

• Potential trigger factors – systematically record stress, fatigue, sleep deprivation, alcohol, specific foods, hormonal changes, weather changes, and other suspected triggers 1, 5
• Menstrual cycle timing – for women, track menstruation dates as hormonal changes are a significant migraine trigger 1, 2

Critical Pitfalls to Avoid

Do not conflate headache diaries with headache calendars – diaries require detailed daily entries about symptoms and medication use, while calendars are simpler tools that only track frequency and timing of headaches 1. Diaries provide the comprehensive information needed for diagnosis and treatment decisions, whereas calendars are better suited for ongoing monitoring after diagnosis is established 1.

Guard against medication-overuse headache – the diary must capture if you're using non-opioid analgesics ≥15 days/month or other acute medications ≥10 days/month for >3 months, as this pattern transforms episodic migraine into chronic daily headache 1, 6. This is one of the most important reasons to maintain accurate medication tracking 1.

Ensure daily completion – retrospective recall is unreliable, and compliance can be challenging (only 46% of patients complete paper diaries consistently in primary care) 1, 2. Electronic diaries may improve compliance and capture more detailed information 1, 7.

Diagnostic Value

Headache diaries reduce recall bias and increase diagnostic accuracy compared to clinical interviews alone 3. A combination of clinical interview and diagnostic headache diary provides qualitatively and quantitatively more precise diagnosis than interview alone 3. The diary helps identify whether attacks consistently meet diagnostic criteria over multiple episodes, which is essential for applying International Headache Society (ICHD-3) criteria 1, 6.

Diaries also help distinguish between different headache types – for example, they identified 20 more cases of episodic tension-type headache and 15 fewer cases of chronic tension-type headache compared to clinical interview alone in one validation study 3. Patients themselves report that daily headache diaries help them identify useful trends over time and are not overly burdensome to complete 8.