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Screening

Returning?

A A A

Headache Surgery Screening

Please complete the following detailed intake form to help us determine if you are a candidate for headache surgery at Massachusetts General Hospital. Please answer all questions that may apply and set aside around 30minutes for completion of this important survey. You do not have to complete the survey in one session and can return to your saved survey with your individual survey code that you will receive via email.

In addition, please complete the pain location survey located on the MGH Migraine Surgery Homepage:

https://www.massgeneral.org/assets/MGH/pdf/surgery/plastic-surgery/Migraine%20Pain%20Location.pdf

THIS FORM IS AN IMPORTANT PART OF THE SCREENING!

We will contact you within three weeks to inform you of the results.

If you have any questions, please call us at 617-724-9922.

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Name

* must provide value

Email

* must provide value

Telephone (best number to reach you)

* must provide value

Telephone (secondary)

Date of birth

* must provide value

M-D-Y

Gender

Female (including transgender women)

Male (including transgender men)

prefer not to disclose

Race

American Indian/Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Black or African American

White

More Than One Race

Unknown / Not Reported

other

prefer not to say

If you answered 'other', please describe

Ethnicity

hispanic or latino

NOT hispanic or latino

Occupation

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

Health insurance company

Have you had your migraines and/or headaches evaluated by one or more neurologists?

* must provide value

Yes

No

Please list the names of all your neurologists.

What diagnoses were you given by your neurologist?

* must provide value

Migraine

Headache

Cluster

Other

Occipital Neuralgia

Trigeminal Neuralgia

Dorsalgia

Cervicogenic Headache

Episodic Migraine

Chronic Migraine

Post Traumatic Headache

I do not have a diagnosis

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

MRI head

MRI neck

CT scan head

CT scan neck

Other

I have not had any of these studies performed

Did your imaging show any abnormalities?

* must provide value

If you answered 'other', please describe

* 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

diabetes

epilepsy

heart attack

stroke

hypertension

hypotension

depression

thyroid disorder

asthma

autoimmune disorder

lupus

mitral valve prolapse

Raynaud's syndrome

other

I do not have any of these diagnoses

If you answered 'other', please describe

* must provide value

Have you been diagnosed with any of the following nerve disorders?

* must provide value

polyneuropathy

carpal tunnel syndrome

cubital tunnel syndrome

median nerve compression

ulnar nerve compression

radial nerve compression

thoracic outlet syndrome

fibromyalgia

shingles

cold sores/ herpes

radiculopathy

brachial plexopathy

sciatica

bell's palsy

other nerve syndrome

I do not have any of these diagnoses

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 migraine headaches do you experience per month (in days; maximum is 30)?

* must provide value

How many regular headaches do you experience per month (in days; maximum is 30)?

* must provide value

Last month, on average how long did your migraines last (in hours, maximum of 24h)

* must provide value

How painful are your migraine headaches on average?
(1=mild; 10= severe)

* must provide value

1

2

3

4

5

6

7

8

9

10

Migraine Headache Index Preop

* must provide value

View equation

How painful are your worst migraine headaches?
(1=mild; 10= severe)

* must provide value

1

2

3

4

5

6

7

8

9

10

Do you migraine headaches ever go away completely? (are there days you have no pain)

* must provide value

Yes

No

How long do your migraine headaches 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?
Check all that apply

* must provide value

Behind right eye

Behind left eye

Behind both eyes

Right temple

Left temple

Both temples

Above right eyebrow

Above left eyebrow

Above both eyebrows

Back of head on right

Back of head on left

Back of head on both sides

Other

If other, please explain

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:

A. Exploding from the inside-out
(buildup of pressure inside of the head as if the skull is about to split open or explode or something squeezing inside the brain)

OR

B. Imploding from the outside-in
(The skull is assaulted by external forces typically described as crushing, clamping and stabbing)

* 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

How would you describe your migraine headaches?
Check all that apply

* must provide value

Throbbing/pounding

Ache/pressure

Like a tight band

Dull

Other

Shock-like

Squeezing

Stabbing

Constricting

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

combing hair

pulling hair back (e.g. ponytail)

wearing eye glasses

wearing earrings

wearing necklaces

resting your face on your pillow on the headache side

wearing tight clothes

allowing the shower to hit your face

cooking (to avoid the heat)

shaving your face

I do not avoid any of these activities

Do your migraine headaches awaken you at night?

* must provide value

Never

Occasionally

Often

Do any of the following occur before or during your migraine headaches?
Check all that apply

* must provide value

Nausea

Vomiting

Diarrhea

Bothered by light/noise

Blurred/double vision

flashing, or colored lights

Eyelid puffy

Eyelid droops

Loss of vision

Feeling lightheaded

Numbness/tingling

Weakness of arm and leg

Difficulty concentrating

Speech difficulty

Loss of consciousness

Runny nose

Other

If you answered 'other', please describe

* must provide value

Do any of the following bring on your migraine headaches or make them worse?

* must provide value

Stress (worry, anger)

Bright sunshine

Weather change

Letdown after stress

Loud noise

Heavy lifting

Air travel

Fatigue

Certain smells or perfume

Missed meals

Sexual activity

Coughing, straining, bending over

Certain foods

Other

If you answered 'other', please describe

* must provide value

Do any of the following make your migraine headaches better?

* must provide value

Rest

Exercise

Quiet and darkness

Hot or cold compress

Massage

Warm shower

Pressure over migraine headache area

Other

If you answered 'other', please describe

* must provide value

If you are female, do your migraine headaches change with the following?
Check all that apply

Menstrual periods

Birth control pills

Pregnancy

Other hormonal drugs

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 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

whiplash (acceleration and deceleration of the head and neck for example during a car crash)

direct strike to the head or head striking an object directly

direct hit to the neck or neck striking an object directly

direct strike to the head and neck or head and neck striking an object directly

other

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

any loss of memory for events immediately before or after the accident <24h

any alteration of mental state at the time of the accident (eg, feeling dazed, disoriented, or confused)

any loss of memory for events after the accident >24h

Please describe the injury mechanism

* must provide value

Did your headache start after your head and/ or neck injury?

* must provide value

Yes

No

When after your head and/or neck injury did your headaches 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 migraine?

* must provide value

Yes

No

Please describe the event that you attribute to the start of your migraine symptoms

* must provide value

Do you think a health disorder is somehow related to your migraine headaches?

* must provide value

Yes

No

Please explain which health disorder is related to your migraine headaches and how you think it is related

* must provide value

To what extent do your migraine headaches affect your quality of life?

* must provide value

Extremely

Moderately

Very little

Not at all

Have your migraines been treated with Botox?

* must provide value

Yes

No

What site was the Botox injected?

* must provide value

back of the head

front of the head

both

other

If you selected other, please describe

* must provide value

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 to treat your headaches/ migraines?

* must provide value

Yes

No

In which area did you have nerve blocks?

* must provide value

back of the head

front of the head

both

other

If you selected other, please describe

* must provide value

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 headaches/ migraines?

* must provide value

Yes

No

In which area did you have the nerve stimulator?

* must provide value

back of the head

front of the head

both

other

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 headaches/ migraines?

* must provide value

Yes

No

In which area did you have the radiofrequency ablation?

* must provide value

back of the head

front of the head

both

other

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

Aspirin

Ibuprofen (Advil, Motrin)

Ketorolac (Toradol)

Excedrin, Anacin, Vanquish

Naproxen (Aleve, Anaprox)

Cortisol

Prednisone

Dexamethasone

I do not take anti- inflammatory medication

other

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

Fiorinal

Vicodin

Percocet

Meperidine (Demerol)

Oxycontin

Oxycodone

Hydrocodone

Fioricet

Tylenol with codeine

Butorphaol (Stadol nasal spray)

I do not take narcotic medication

Other

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

Gabapentin (Neurontin)

Pregabalin (Lyrica)

Duloxetine (Cymbalta)

Baclofen (Lioresal, Gablofen)

I do not take nerve medications

other

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

Ondansetron (Zofran)

Prochlorperazine (Compazine)

Metoclopramide (Reglan)

other

I do not take anti- nausea medications

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

If yes, please list them

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