Keeping a headache diary

NINDS gives the same field list on its headache page and its migraine page, introduced with the instruction to write these down after each headache (NINDS):

• The time of day when it happened
• How intense it was and how long it lasted
• Any sensitivity to light, smells, or sound
• Any activity right before the headache started
• Any medicines taken, including both prescription and over-the-counter
• The quality and length of the previous night's sleep
• Any stress or strong emotions before developing symptoms
• The weather or changes in daily routine
• Food and drinks consumed in the previous 24 hours
• Any other health conditions

Two lines follow that list on the same page. People who menstruate can record the days of their periods, and notes about other family members who have a history of headache conditions or other health conditions are also helpful (NINDS).

Two fields people expect are missing from that list, and both sit on NIH's own printed sheet instead. The Migraine Trainer Weekly Migraine Log asks for severity of migraine on a scale of 1 to 10, where 1 is barely noticeable and 10 is worst pain imaginable, and it asks for location of migraine, offering one side of head, both sides, middle, or all over (NINDS Migraine Trainer log). The same sheet asks for the number of migraines, the time the migraine started, the hours it lasted, the action taken, warning signs, and the trigger, and it carries four daily rows underneath for sleep in hours, exercise in minutes, glasses of water or non-caffeinated liquid, and meals eaten in the past 24 hours (NINDS Migraine Trainer log).

MedlinePlus keeps a shorter version, saying a headache diary can help you identify your headache triggers and asking you to write down the day and time the pain began, what you ate and drank over the past 24 hours, how much you slept, what you were doing and where you were right before the pain started, and how long the headache lasted and what made it stop (MedlinePlus). It also says what the record is for, which is to review your diary with your health care provider to identify triggers or a pattern to your headaches (MedlinePlus).

NICE writes the clinician's version, asking the person to record frequency, duration and severity of headaches, any associated symptoms, all prescribed and over the counter medications taken to relieve headaches, possible precipitants, and relationship of headaches to menstruation (NICE CG150). The phrase carrying the most weight there is all prescribed and over the counter medications, since the drugstore pills are the ones that go unmentioned at the appointment.

NICE asks for a minimum of 8 weeks, wording it as an instruction to ask the person to record the fields above for that long (NICE CG150). ICHD-3 sets a shorter floor and a stricter cadence, saying that characterization of frequently recurring headache generally requires a headache diary to record information on pain and associated symptoms day-by-day for at least one month (ICHD-3). The phrase doing the work there is day-by-day, because the record ICHD-3 wants covers the days without a headache too.

Menstrual timing takes longer to establish. NICE asks for a headache diary kept for at least 2 menstrual cycles before diagnosing menstrual-related migraine (NICE CG150), and ICHD-3 states its own criterion as a proportion, looking for attacks in at least two out of three menstrual cycles (ICHD-3).

No US source states a duration at all. NINDS says to write things down after each headache, MedlinePlus says when you get a headache, and neither attaches a number of weeks, so the 8 weeks belongs to NICE, a UK guideline, and the one month belongs to ICHD-3, an international classification.

Chronic migraine is defined by two numbers on the same record. ICHD-3 describes it as headache occurring on 15 or more days a month for more than 3 months, which, on at least 8 days a month, has the features of migraine headache (ICHD-3). NINDS states the first half in plain words, saying chronic migraine happens when headaches from migraine happen on at least 15 days of the month for more than three months (NINDS). Use 15 or more, since AMF words the boundary as more than 15 headache days per month (AMF, February 12, 2018), which would leave out somebody sitting at exactly 15.

Medication-overuse headache runs on a second set of counts, and which count applies depends on what is in the bottle. ICHD-3 puts the threshold at 10 or more days a month for ergotamine, for triptans, for opioids and for combination analgesics, and at 15 or more days a month for paracetamol or acetaminophen, for NSAIDs including acetylsalicylic acid, and for other non-opioid analgesics, every one of them for more than 3 months, in somebody who already has headache on 15 or more days a month (ICHD-3). NICE gives the same split in one sentence, telling clinicians to be alert to the possibility of medication overuse headache in people whose headache developed or worsened while they were taking triptans, opioids, ergots or combination analgesic medications on 10 days per month or more, or paracetamol, aspirin or an NSAID, either alone or in any combination, on 15 days per month or more, for 3 months or more (NICE CG150).

One more ICHD-3 row is the reason a written total beats a guess. It covers regular intake of any combination of ergotamine, triptans, non-opioid analgesics and/or opioids on a total of 10 or more days a month for more than 3 months without overuse of any single drug or drug class alone (ICHD-3). Dr. Deborah Friedman puts the same point to patients in AMF's article on medication overuse headache, saying it's a total, and that if you're taking a certain number of simple analgesics and a certain number of triptans, you have to add them all up (AMF, January 15, 2018). The same article says many patients don't factor in their use of over-the-counter medication when describing how often they take migraine medications to their doctors (AMF, January 15, 2018), which is the whole argument for writing every pill down on the day you swallow it.

ICHD-3 is candid about where its own figures came from, saying the specified numbers of days of medication use considered to constitute overuse are based on expert opinion rather than on formal evidence (ICHD-3).

Three documents give a threshold for taking painkillers too often, and the numbers are far apart. The NHS says to try not to take painkillers for more than 2 days a week, because this can cause you to get more headaches and make migraine harder to treat (NHS, Migraine). MedlinePlus says people who take pain medicine more than 3 days a week on a regular basis can develop this type of headache, and tells you to talk to your provider if you are taking pain medicines 3 or more days a week (MedlinePlus). ICHD-3 and NICE work in days per month instead, at 10 or 15 depending on the drug class, for more than 3 months (ICHD-3, NICE CG150).

They are answering different questions. The weekly figures say when to raise it with somebody, and the monthly figures say when it becomes a diagnosis, so averaging them would produce a number that no document states. AMF's specialist lands near the weekly end, saying that when patients need to use their acute medications more than two or three days per week, that's the first red flag (AMF, January 15, 2018).

Four documents name a frequency at which prevention comes up, and they name four different frequencies. AHS says preventive treatments for migraine should be considered for patients with four or more headache days a month (AHS). NINDS words it weekly, saying people who have migraine episodes once a week or more are usually prescribed treatment to prevent them from happening (NINDS). MedlinePlus says that if your migraines occur more than twice a week, your provider may recommend medicines to take every day (MedlinePlus). AMF sets the lowest bar, saying that if you consistently have two or more headaches each month and you're not receiving preventive treatment, it's time to find a headache specialist to explore your prevention options (AMF, February 12, 2018).

Averaging those four would invent a figure none of them state, so all four are here with their names on them. The count itself is the part a diary settles, and whichever threshold your clinician works from, the answer to how many days last month is either written down or guessed at.

Each list below belongs to the document named beside it, and the lists disagree with each other, so none of them is a checklist to work through.

NINDS names foods and ingredients that may trigger headache attacks, especially migraine attacks, in some people: aged cheeses, aspartame, caffeine or caffeine withdrawal, chocolate, cured or processed meats such as deli meats, monosodium glutamate, nuts especially salted ones, and wine and other types of alcohol (NINDS). Its non-food list is emotional stress, weather changes, changes in eating and sleep patterns, and dehydration (NINDS), and its migraine page adds sudden changes in the weather or a person's environment, too much or not enough sleep, strong smells, emotional stress, physical strain on the body, loud or sudden noises, motion sickness, low blood sugar or skipped meals, tobacco, drinking too much alcohol, some medicines, hormonal changes, and bright or flashing lights (NINDS).

The NIH log prints its own sample list for the person filling it in, covering bright lights, loud unpleasant noise, travel, strong smells, weather, tiredness, stress, coffee or energy drinks, not drinking enough water, skipping a meal, alcohol, drugs, missing a dose of your headache medication, staying up late, and the menstrual cycle (NINDS Migraine Trainer log). A missed dose of your own headache medication is on that list, which is a thing worth writing down on the day it happens.

The NHS lists having a cold or flu, stress, drinking too much alcohol, bad posture, eyesight problems, not eating regular meals, dehydration, taking too many painkillers, and having your period or going through menopause among common causes of headaches, and says on the same page that keeping a headache diary might help you work out what triggers your headaches (NHS). Its migraine page names having your period, anxiety and depression, stress and tiredness, skipping meals or not eating regularly, too much caffeine, and not getting enough regular exercise (NHS). MedlinePlus lists caffeine withdrawal, changes in hormone levels during a woman's menstrual cycle or with the use of birth control pills, changes in sleep patterns, drinking alcohol, exercise or other physical stress, loud noises or bright lights, missed meals, odors or perfumes, smoking or exposure to smoke, and stress and anxiety, alongside a food list headed by chocolate, dairy foods, foods with monosodium glutamate, foods with tyramine, some fruits, meats containing nitrates, onions, nuts and seeds, and processed, fermented, pickled or marinated foods (MedlinePlus).

AMF ranks ten of them, in this order: stress, changes in or an irregular sleep schedule, hormones, caffeine and alcohol, changes in the weather, diet, dehydration, light, smell, and medication overuse (AMF, July 27, 2017). That article's figures are its own and carry no study citations, so they travel with its name and date: stress is a trigger for almost 70% of people with migraine, up to 75% of women find that they experience attacks around the time of their menstrual period, and about one third of people with migraine say dehydration is a trigger (AMF, July 27, 2017). It closes by saying that everyone's experience with migraine and migraine triggers is different (AMF, July 27, 2017), which is the sentence that makes a personal record worth more than any of these lists.

Sleep cuts both ways, which is why the diary asks for the hours rather than a verdict. NINDS says that generally, too little or too much sleep can worsen headaches, and that daytime naps often lower deep sleep at night and can cause headaches in some adults (NINDS). The NHS says the same from the other side in its self-care advice, telling you not to sleep more than you usually would because it can make the headache worse (NHS).

Menstrual timing has an exact window in the classification. ICHD-3 defines pure menstrual migraine without aura by attacks occurring exclusively on day 1 plus or minus 2, meaning days minus 2 to plus 3 of menstruation, in at least two out of three menstrual cycles and at no other times of the cycle, and it notes that the first day of menstruation is day 1, the preceding day is day minus 1, and there is no day 0 (ICHD-3). NICE states the same window in plain words, saying to suspect menstrual-related migraine if migraine occurs predominantly between 2 days before and 3 days after the start of menstruation in at least 2 out of 3 consecutive menstrual cycles (NICE CG150).

Two documents define how fast a thunderclap headache peaks, and they give different numbers. AMF quotes Alison Thaler, MD, describing it as a severe headache that reaches maximal intensity within one minute, and says that if you are experiencing this type of headache pain for the first time you should visit the emergency department, because a thunderclap headache could be benign but may also be a sign of a serious underlying condition such as an aneurysm rupture (AMF, June 14, 2023). NICE uses five minutes, asking clinicians to evaluate people who present with sudden-onset headache reaching maximum intensity within 5 minutes (NICE CG150).

Both are on the record and neither one cancels the other. This page leads with AMF's one minute because it is the US patient source, and NICE's five minutes is written for the person examining you.

I never diagnose and I never tell you what to take. What I do is ask one question a day, keep your answers with the dates on them, read the pattern back whenever you want it, and hand you the record before the appointment so the visit starts from what happened rather than from what you can reconstruct in the chair. When what you describe is on the red-flag list above, I say so plainly and tell you to call.

The daily cadence is a choice I made rather than a clinical recommendation. ICHD-3 asks for a record kept day-by-day for at least one month (ICHD-3), and AMF says that updating a headache journal shouldn't feel like an overwhelming task and that you may only update your journal on days when you have a headache or other symptoms (AMF, April 8, 2025), so one short question a day is where I land.

Counting is the part I am genuinely useful for. NICE wants frequency, duration, severity, associated symptoms, all prescribed and over the counter medications, possible precipitants, and the relationship of headaches to menstruation (NICE CG150), and every one of those is something you can text me in a sentence on the day it happens. MedlinePlus says to review your diary with your health care provider to identify triggers or a pattern to your headaches (MedlinePlus), and that review is what the whole record is for.

No clinician reviewed this page. It restates the NINDS pages, the NIH Migraine Trainer log, MedlinePlus, the NHS, NICE CG150, ICHD-3, and the AMF and AHS pages linked below, and those are the documents to trust over anything here.