For staff only:
Yes
No
Email
* must provide value
We only use your email adress to send you study surveys if you can not come to your appointment
Telephone (best number to reach you)
* must provide value
Date of birth
* must provide value
Today M-D-Y
Female (including transgender women)
Male (including transgender men)
Prefer not to disclose
If you answered 'other', please describe
hispanic or latino
NOT hispanic or latino
Current work status
* must provide value
working full time
working, part time
homemaker
retired
unemployed- able to work
unemployed- unable to work
on worker's comp
currently on sick leave
other
If you answered 'other', please describe
On average, how many days per month do you miss work (0-30)?
* must provide value
On average, how many days a month do you go to work with a headache, but cannot work as well (0-30)?
* must provide value
Have you had your migraines and/or headaches evaluated by one or more neurologists?
* must provide value
Yes
No
How many different neurologists did you visit?
* must provide value
Please list the names of all your neurologists.
* must provide value
How many different specialties did you visit to seek treatment for your headache symptoms?
* must provide value
What diagnoses were you given by your neurologist?
* must provide value
If you answered 'other', please describe
* must provide value
Have you had any of the following radiology studies (if you answered yes, please bring a copy of your report and the discs to your appointment):
* must provide value
Did your imaging show any abnormalities?
* must provide value
If you answered 'other', please describe
* must provide value
How many times did you visit the Emergency Department to seek treatment for your headache?
* must provide value
Do you smoke?
* must provide value
Yes
No
How would you rate your general health?
* must provide value
Excellent
Good
Fair
Poor
Have you been diagnosed with any of the following health disorders?
* must provide value
If you answered 'other', please describe
* must provide value
Have you been diagnosed with any of the following nerve disorders?
* must provide value
If you answered 'other', please describe
* must provide value
Have you been diagnosed with Temporomandibular joint (TMJ) disease?
* must provide value
Yes
No
Do you have other pain conditions
* must provide value
Yes
No
Which pain conditions do you suffer from?
* must provide value
How many days per month do you experience pain in the head and neck region (in days; maximum is 30)?
* must provide value
Which type of pain are you experiencing?
* must provide value
How many nerve pain headaches do you experience per month (in days; maximum is 30)?
* must provide value
please enter numbers only
How many migraine headaches do you experience per month (in days; maximum is 30)?
* must provide value
please enter numbers only
How many regular headaches do you experience per month (in days; maximum is 30)?
* must provide value
please enter numbers only
Last month, on average how long did your nerve pain headaches last (in hours, maximum of 24h)
* must provide value
Last month, on average how long did your migraines last (in hours, maximum of 24h)
* must provide value
Last month, on average how long did your regular headaches last (in hours, maximum of 24h)
* must provide value
How painful are your nerve pain headaches on average?
* must provide value
1
2
3
4
5
6
7
8
9
10
How painful are your migraine headaches on average?
* must provide value
1
2
3
4
5
6
7
8
9
10
How painful are your headaches on average?
* must provide value
1
2
3
4
5
6
7
8
9
10
Migraine Headache Index Preop
* must provide value
View equation This field will be calculated automatically
How painful are your worst nerve pain headaches?
* must provide value
1
2
3
4
5
6
7
8
9
10
How painful are your worst migraine headaches?
* must provide value
1
2
3
4
5
6
7
8
9
10
How painful are your worst headaches?
* must provide value
1
2
3
4
5
6
7
8
9
10
If you answered "other", please describe.
Does your pain ever go away completely? (are there days you have no pain)
* must provide value
Yes
No
How long does your pain usually last after you take your migraine medicine?
* must provide value
No more than two hours
3-4 hours
5-12 hours
12-24 hours
Several days, one week or longer
Where do your migraines usually start?
* must provide value
Where do your nerve pain headaches usually start?
* must provide value
Where do your regular headaches usually start?
* must provide value
Do you grind your teeth?
* must provide value
Yes
No
Do you have deep frown lines?
* must provide value
Yes
No
Does your pain radiate to your forehead, eye brow, or behind the eye?
* must provide value
forehead
eyebrow
behind the eye
my pain does not radiate towards the front and stays on the back of my head
Does your pain radiate to your ear?
* must provide value
Yes
No
Do you experience dizziness?
* must provide value
Yes
No
Do you have tight neck muscles?
* must provide value
Yes
No
Is your pain more prominent on the right side, left side, or equal on both sides?
* must provide value
right
left
both sides
Does it feel like your pain is:
* must provide value
Exploding
Imploding
I don't know
Other
Please explain "other"
* must provide value
How old were you when your migraine headaches started (in years)?
* must provide value
please enter numbers only
How old were you when your nerve pain headaches started (in years)?
* must provide value
please enter numbers only
How old were you when your regular headaches started (in years)?
* must provide value
please enter numbers only
How would you describe your nerve pain headaches?
* must provide value
How would you describe your migraine headaches?
* must provide value
How would you describe your regular headaches?
* must provide value
If you answered 'other', please describe
* must provide value
Do you avoid any of the following activities because they cause you pain (check all that apply)?
* must provide value
Do you avoid any of the following activities because they cause you pain (check all that apply)?
* must provide value
Does your pain awaken you at night?
* must provide value
Never
Occasionally
Often
Do any of the following occur before or during your pain (migraine, nerve pain headaches, regular headaches, other)?
* must provide value
If you answered 'other', please describe
* must provide value
Do any of the following bring on your pain or make them worse?
* must provide value
If you answered 'other', please describe
* must provide value
Do any of the following make your pain better?
* must provide value
If you answered 'other', please describe
* must provide value
If you are female, do your pain change with the following?
If you answered 'other', please describe
* must provide value
Do any of your family members have migraine headaches?
* must provide value
Yes
No
Who in your family has migraines? (please list all family members)
* must provide value
Have you ever been diagnosed with a cervical spine disorders?
* must provide value
Yes
No
Have you had cervical spine surgery?
* must provide value
Yes
No
If yes, what procedure did you have?
Have you had a neurosurgical procedure?
* must provide value
Yes
No
If yes, what procedure did you have?
If other, please describe
Have you ever had a head or neck injury requiring medical treatment?
* must provide value
Yes
No
What type of head and neck injury did you experience?
* must provide value
If you answered 'other', please describe
* must provide value
Did you loose consciousness?
* must provide value
Yes
No
For how long did you lose consciousness?
* must provide value
<1 minute
1-30 minutes
>30 minutes
>24h
Did you experience any of the following symptoms after your injury (check all that apply):
* must provide value
Please describe the injury mechanism
* must provide value
Did your head pain start after your head and/ or neck injury?
* must provide value
Yes
No
When after your head and/or neck injury did your head pain start?
* must provide value
the same day
within 7 days after my injury
within 14 days after my injury
within 1 month of my injury
within 3 months of my injury
within 6 moths of my injury
within 1 year of my injury
other
If you answered 'other', please describe
* must provide value
Was there any other event that triggered your pain?
* must provide value
Yes
No
Please describe the event that you attribute to the start of your head pain symptoms
* must provide value
Do you think a health disorder is somehow related to your pain?
* must provide value
Yes
No
Please explain which health disorder is related to your head pain and how you think it is related
* must provide value
Do you think COVID-19 is related to you pain?
Yes
No
Please describe how you think COVID-19 is related to you pain.
To what extent does your pain affect your quality of life?
* must provide value
Extremely
Moderately
Very little
Not at all
Do you experience cervical spasms?
Yes
No
On what side do you experience spasms?
Have you been diagnoses with one of the following disorders?
If you received one of the following interventions for your cervical disorder, if so, which were effective?
How much can you turn your head to the right or left?
0°
< 1/4 range, 1°- 22°
1/4 - 1/2 range, 23°- 45°
1/2 - 3/4 range, 46°- 67°
>3/4 range, 68°-90°
This is a picture demonstrating a tilted head.
How much is your head tilted to the right or left?
0 = None [0°]
1 = Mild [1°-15°]
2 = Moderate [16°-35°]
3 = Severe [> 35°]
How much is your head tilted forward?
0 = None
1 = Mild downward deviation of chin
2 = Moderate downward deviation (approximates 1/2 possible range)
3 = Severe (chin approximates chest)
How much is your head tilted backward?
0 = None
1 = Mild backward deviation of vertex with upward
deviation of chin
2 = Moderate backward deviation (approximates 1/2
possible range
3 = Severe (approximates full range)
This picture is demonstrating a patient with a lateral shift (The head is at angle (90 degrees) to the shoulder line, but is shifted to the right.
Does your head shift to the right or left?
No
Yes
Does your head shift forward or backward?
No Yes
How often do you experience neck deviation?
0: My head is always in a normal position. 1: My head tilts occasionally (less than 25% of the time), but it's usually not extreme. 2: My head tilts occasionally (less than 25% of the time) and is often more extreme, or it tilts intermittently (25-50% of the time) but usually not very much. 3: My head tilts intermittently (25-50% of the time) and is often more extreme, or it frequently tilts (50-75% of the time) but usually not very much. 4: My head frequently tilts (50-75% of the time) and is often extreme, or it is always tilted (more than 75% of the time) but usually not very much. 5: My head is always tilted (more than 75% of the time) and is often extreme.
Do any tricks help relieve your symptoms?
0: The tricks give me complete relief. 1: The tricks help a little, but not a lot. 2: The tricks don't help me at all. 3= I don't have any tricks
Do your shoulders lift or move forward because of your neck condition?
0: No, there's no lifting at all. 1: There's a mild lift (less than one-third of the range), and it happens sometimes or all the time. 2: There's a moderate lift (one-third to two-thirds of the range) that's constant, or a severe lift (more than two-thirds) that happens intermittently. 3: The lift is severe and constant
How well can you move your head to the opposite side?
0: Yes, I can turn all the way. 1: I can turn well past the middle but not all the way. 2: I can turn just a little past the middle. 3: I can only turn my head toward the middle. 4: I can barely move my head.
How long can you keep your head in a straight position?
0 = > 60 seconds 1 = 46-60 seconds 2 = 31-45 seconds 3 = 16-30 seconds 4 = < 15 seconds
How much difficulty do you have with work or chores because of your neck condition?
0: I have no difficulty at all. 1: I can work normally, but my neck sometimes gets in the way. 2: I can do most tasks, but some are very difficult and take more effort. 3: I'm working at a lower level; most tasks are hard, but I can still manage. 4: I can't work regularly, but I can still do some household tasks. 5: I have little or no ability to do household responsibilities.
How does your neck condition affect daily activities like eating or dressing?
0: I have no difficulty with any activities. 1: I can do everything, but my neck sometimes interferes. 2: I can do most things, but some are very difficult and I need simple tricks to help. 3: Most activities are hard or take a lot of effort, but I can still do them with special tricks. 4: All activities are affected; some are impossible or I need help with them. 5: I rely on others for most self-care tasks.
How does your neck condition affect your ability to drive?
0: I have no difficulty driving (or I've never driven). 1: I can drive, but I'm sometimes bothered by my neck. 2: I can drive, but I need to use tricks to help me, like holding my head in a certain way. 3: I can only drive short distances. 4: I usually can't drive because of my neck. 5: I can't drive at all and can't be a passenger for long because of my neck.
How much can you read comfortably with your neck condition?
0: I can read without any difficulty. 1: I can read normally, but I'm sometimes bothered by my neck. 2: I can read normally, but I need to use tricks to help me. 3: I can read, but I have to take special measures or can only read while lying down. 4: I have a lot of trouble reading because of my neck, even with tricks. 5: I can't read more than a few sentences because of my neck.
How much difficulty do you have watching TV?
0: I have no difficulty watching at all. 1: I can watch normally, but I'm sometimes bothered by my neck. 2: I can watch normally, but I need to use tricks to help me. 3: I can watch, but I have to take special measures or can only lie down. 4: I can only watch for a short time because of my neck. 5: I can't watch for more than a few minutes because of my neck.
How does your condition affect your ability to go out and do activities?
0: I have no difficulty doing anything. 1: I can do everything, but I'm sometimes bothered by my neck. 2: I can do everything, but I need to use simple tricks to help me. 3: I can only do these activities if someone is with me. 4: I have a lot of trouble with activities outside; some I can't do at all. 5: I rarely go out or do activities outside
On a scale from 0 to 10, how would you rate your neck pain over the last week, where 0 is no pain and 10 is the worst pain imaginable? Please tell me your best pain level?
On a scale from 0 to 10, how would you rate your neck pain over the last week, where 0 is no pain and 10 is the worst pain imaginable? Please tell me your worst pain level?
On a scale from 0 to 10, how would you rate your neck pain over the last week, where 0 is no pain and 10 is the worst pain imaginable? Please tell me your usual pain level?
How often do you experience neck pain?
0 = None
1 = Present < 10% of the time
2 = Present 10% -25% of the time
3 = Present 26% - 50% of the time
4 = Present 51% -75% of the time
5 = Present > 76% of the time
How much does your pain limit your activities?
0 = No limitation or interference from pain
1 = Pain is quite bothersome but not a source of disability
2 = Pain definitely interferes with some tasks but is not a major contributor to disability
3 = Pain accounts for some (less than half) but not all of disability
4 = Pain is a major source of difficulty with activities; separate from this, head pulling is also a source of some (less than half) disability
5 = Pain is the major source of disability; without it most impaired activities could be performed quite satisfactorily despite the head pulling
Do you have large breasts (macromastia)?
Yes
No
Do you experience back pain or neck pain caused by large breasts?
Yes
No
What is your daily screen time (time spent using an electronic device with a screen (such as a smartphone, tablet or laptop))?
< 1 hour
1 hour
2 hours
3 hours
4 hours
5 hours
6 hours
> 6 hours
Have your pain been treated with Botox?
* must provide value
Yes
No
What site was the Botox injected?
* must provide value
If you selected other, please describe
* must provide value
How many botox injections have you had?
What was the best response you had to Botox injections?
* must provide value
no relief (0%)
some relief (< 50%)
significant relief (>50%, but not complete)
complete relief (100%)
For how long did your best Botox treatment work?
* must provide value
< one week
< one month
< 2 months
< 3 months
>3months, < 6 months
>6 moths
other
If you selected other, please describe
* must provide value
Are you still using Botox?
* must provide value
Yes
No
Is Botox still effective?
* must provide value
Yes
No
Have you ever had nerve blocks (AKA lidocaine or other anesthetic injections) to treat your pain?
* must provide value
Yes
No
In which area did you have nerve blocks?
* must provide value
If you selected other, please describe
* must provide value
How many nerve blocks have you had?
Did your nerve block injections help?
* must provide value
no relief (0%)
some relief (< 50%)
significant relief (>50%)
complete relief (100%)
For how long did your Nerve block injection work?
* must provide value
< 1 hour
< 6 hours
< 12 hours
< 24h
< 48h
< 72h
>72h, but under one week
> one week, but under two weeks
>2 weeks, but under 1 month
> 1 month, but under 3 months
>3 months, but under 6 months
>6 months
other
If you listed other, please describe
* must provide value
Have you ever had a nerve stimulator to treat your head pain?
* must provide value
Yes
No
In which area did you have the nerve stimulator?
* must provide value
If you selected other, please describe
* must provide value
For how long did your Nerve stimulator work?
* must provide value
< one week
< one month
< 2 months
< 3 months
>3months, < 6 months
>6 moths, < 1 year
>1 year
other
If you selected other, please describe
* must provide value
Have you ever had radiofrequency ablation to treat your head pain?
* must provide value
Yes
No
In which area did you have the radiofrequency ablation?
* must provide value
More specifically, was the radiofrequency performed at the level of the cervical spine or direction on a nerve in the back of your head?
* must provide value
If you selected other, please describe
* must provide value
For how long did your radiofrequency ablation work?
* must provide value
< one week
< one month
< 2 months
< 3 months
>3months, < 6 months
>6 moths, < 1 year
>1 year
other
If you selected other, please describe
* must provide value
List any other treatments that were not medications in the past
Please check any current anti-inflammatory medications you are taking:
* must provide value
If you selected other, please list the other anti-inflammatory medications you are taking
* must provide value
How many times over the last month have you used anti- inflammatory medication (in days; maximum is 30)?
* must provide value
Please check any current Preventative medications you are taking (common brand names are listed in parenthesis, but it is possible that you are taking a different brand. Therefore, please check all the active ingredients that are in your headache drugs):
* must provide value
Propanolol (Inderal)
Timolol (Timoptic, Istalol)
Atenolol (Tenormin)
Nadolol (Cogard)
Metoprolol (Lopressor, Toprol)
Verapamil (Calan, Verelan)
Diltiazem (Cartia XT, Tiazac, DiltXR)
Amitriptyline (Elavil)
Nortriptyline (Pamelor)
Topiramate (Topamax)
CGRP inhibitors (Aimovig, Ajovy, Emgality)
Clonidine (Catapres)
Feverfew
Phenytoin (Dilantin)
Valproic acid (Depakote)
Sertraline (Zoloft)
Paroxetine (Paxil)
Fluoxetine (Prozac)
Venlafaxine (Effexor)
Bupropion (Wellbutrin)
Trazodone (Desyrel, Oleptro)
Proptriptyline (Vivactil)
Desipramine (Norpramin)
Imipramine (Tofranil)
Doxepin (Silenor, Zonalon, Prudoxin)
Methysergid (Sansert)
I do not take preventative medication
Other
If you selected other, please list the other preventative medications you are taking
* must provide value
How many times over the last month have you used preventative medication (in days; maximum is 30)?
* must provide value
Please check any current abortive medications you are taking (common brand names are listed in parenthesis, but it is possible that you are taking a different brand. Therefore, please check all the active ingredients that are in your headache drugs):
* must provide value
Ergotamine (Cafergot, Ergostat, Wigraine, Migrainal nasal spray)
Triptans: e.g. Sumatriptan (Imitrex, Treximet), Almotriptan (Axert), Naratriptan (Amerge), Eletriptan (Relpax), Rizatriptan (Maxalt), Zolmitriptan (Zomig), Frovatriptan (Frova)
Acetaminophen (Tylenol)
Isomephtene/ dichloralphenazone/APAP (Midrin)
Phrenilin
I do not take abortive medication
other
If you selected other, please list the other abortive medications you are taking
* must provide value
How many times over the last month have you used abortive medication (in days; maximum is 30)?
* must provide value
Please check any current opioid medications you are taking (common brand names are listed in parenthesis, but it is possible that you are taking a different brand. Therefore, please check all the active ingredients that are in your headache drugs):
* must provide value
If you selected other, please list the other opioid medications you are taking
* must provide value
How many times over the last month have you used opioid medication (in days; maximum is 30)?
* must provide value
Please check all the nerve specific medications you take (common brand names are listed in parenthesis, but it is possible that you are taking a different brand. Therefore, please check all the active ingredients that are in your headache drugs):
* must provide value
If you selected other, please list the other nerve medications you are taking
* must provide value
How many times over the last month have you used nerve medication (in days; maximum is 30)?
* must provide value
Please check all the anti- nausea medications you take (common brand names are listed in parenthesis, but it is possible that you are taking a different brand. Therefore, please check all the active ingredients that are in your headache drugs):
* must provide value
If you selected other, please list the other anti- nausea medications you are taking
* must provide value
How many times over the last month have you used anti- nausea medications (in days; maximum is 30)?
* must provide value
Are there any other medications that you are taking?
* must provide value
Do you have difficulty breathing through your nose?
* must provide value
Yes
No
Have you ever had a broken nose?
* must provide value
Yes
No
Do you experience sinus headaches?
* must provide value
Yes
No
Have you ever had surgery for your breathing or sinus surgery?
* must provide value
Yes
No
Please list the types of airway/ sinus surgery you have had
Are you a mouth breather?
* must provide value
Yes
No
Do you snore?
* must provide value
Yes
No
Do you take over-the-counter nose sprays and decongestants?
* must provide value
Yes
No
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