If you have migraines or you are treating patients with migraines, you are likely familiar with the idea of a headache diary.
A headache diary is simply a record of headache episodes but is an absolute necessity to guide treatment decisions related to migraines. It provides insight into subtle headache patterns and triggers that may not otherwise be noticed.
I am aware that keeping a calendar of headaches may be perceived as a tedious undertaking. In my patients with daily headaches I am often met with the response “why do I need to track them? I know I have headaches every day.” This is an understandable response. Who wants an additional reminder of their daily suffering when they know they have constant pain? We need to remember that retrospective accounts of symptoms are known to be inaccurate. These inaccuracies can result in missed attributes of headaches and their patterns. Small details that can help us manage pain.
When a new treatment is started it may seem as though it is not improving symptoms. However, a headache diary could reveal a reduction in headache intensity, improved function, or a change in use of acute medication. These factors can help inform clinical decisions.
Here are some of the clinical decisions that I have collaboratively made with patients because of the information in a headache diary:
1. Target a trigger. Triggers are the situations or conditions that can set off a migraine attack. Sometimes they are out of our control, like the weather. They can also be certain foods, hydration levels, sleep, and stress levels. If we can capture triggers in a headache diary, we can take steps to avoid them or mitigate their effect on migraines.
2. Start a medication for prevention. This is a difficult decision for many patients. Starting a daily prescriptive medication may seem like a big step from using medications only when migraines arise. Starting prevention early creates a greater likelihood of gaining control over worsening headaches. Every year approximately 2% of migraine sufferers will transition to having chronic migraines (meaning they have headaches on 15 or more days each month). Chronic migraines are much more difficult to treat. When headaches start to become more frequent, earlier prevention is more effective.
3. Stick with a medication or optimize the dosage. When I do start preventative medications, I start low and go slow. This means starting at a very low dose and increasing that dose very slowly over several weeks. This can help reduce potential side effects and increase tolerability to the medication. A headache diary can help to assess even some small improvement. This could indicate that a medication just needs more time to reach peak effect or perhaps needs a slight dosage increase. These subtleties can be lost if we do not have the objective information contained in a headache diary.
4. Target predictable migraine episodes. A good example are menstrual migraines. These tend to occur at specific times during a menstrual cycle. When women experience these types of migraines, we can develop a specific plan to predict and target episodes and ideally prevent or reduce the intensity and duration of an attack. A headache diary is the only way to accurately determine the specific timing to launch our counterattack!
5. Stop a medication. It is amazing when migraines improve to the point where we stop preventative medications. This is usually after a stable reduction for at least 6 months. Again, it is difficult to make this decision unless we look at a long-term pattern in headache frequency. Also, a diary may reveal absolutely no effect from a medication after an adequate period (typically 8 weeks or more). Note: any intolerable side effect is a reason to stop a medication regardless of the effect on headaches.
6. Avoid a Medication Overuse Headache (MOH). This is an actual diagnosis and occurs when an individual uses their acute migraine medication on too many days each month (this can be over-the-counter OR prescriptive medications used for migraine attacks). Relying on acute medication too much usually means preventative strategies are inadequate. (Note: if you are using acute medication 10 or more days each month for your migraines, you should see your healthcare provider to talk about your headaches)
What is the best diary to use? I personally love recommending Canadian Migraine Tracker.
This is my favourite migraine tracking app! It is completely free, available for iOS and android, and developed by Canadian experts in headache care through the Canadian Headache Society. The app was created within the last year and is actively being improved with new features. I have no vested interest in this app and receive no compensation for this recommendation. I like the app because it makes it much easier for me to understand important clinical details about my patient’s migraines and patients appreciate the ease of use. It has a calendar interface and uses a simple 0-1-2-3 scale to record the impact of your migraine on daily function. Canadian Migraine Tracker can generate a simple summary that can be emailed to a healthcare provider, printed out, or quickly reviewed during an appointment. You can track minimal details such as frequency and severity OR include more elaborate information about time of day, associated symptoms, menstrual cycle, behavioural strategies (i.e. meditation, relaxation), and effectiveness of medications.
So how do you convince a migraine sufferer to track their headaches? I usually say that the information is helpful to me as their healthcare provider, but it is invaluable to them. The more a migraine sufferer can learn about their own migraines, triggers, and patterns, the more empowered they are to manage them.
Now that we are all onboard with keeping a headache diary, how should we do it? I prefer to start with a simple approach to make sure this is a sustainable habit.
1. Track the number of headache days each month. Even if a single migraine lasts 4 days, that counts as 4 headache days. Remember that 15 or more days of headache per month is considered a “chronic” headache. Does the duration matter? The answer is yes, but it can be hard to track the start and end of a headache. An important note is whether headaches last longer than 4 hours or less than 4 hours – as this can give us clues to different types of headache diagnoses.
2. Track the severity. This is where I throw the 0 to 10 pain scale out the window. Headache experts in Toronto developed the Traffic Light Headache Scale which I love to use (Lagman & Lay, 2019). This is a scale that individuals use to describe the impact a headache has on their function. Canadian Migraine Tracker has adopted this into a 1-2-3 scale with the same premise.
This is how it is described (think of a green-yellow-red traffic light):
A GREEN headache – means that you can still “go” and fully function.
A YELLOW headache – means that your function is “slowed”.
A RED headache – means that you need to “stop” and rest. These headaches may put you to bed and cause you to miss work or social functions.
3. Track your medication usage. I’m referring to acute or “rescue” medication usage. This is the medication used during an attack to get some relief. It can be over the counter (OTC) such as acetaminophen or ibuprofen. Or it could be prescriptive medication such as a triptan or prescriptive NSAID. The reason this is important is because it is possible to develop a medication overuse headache from using too much acute medication (I’ll talk about this in a future post). Ultimately you want to try to limit acute medications to a MAXIMUM of 10 days per month (15 for some medications, but I try to keep this message simple), because you can develop a rebound type headache from relying on the acute medication. This is also a reason to consider a daily preventative medication for migraines.
4. Bonus info! Any additional information that patients can track is always helpful. Some of these details could be character of headache, time of onset, known triggers, menstrual cycle, and non-medication management strategies etc.
In Summary……. A headache diary:
· Quantifies the number of headaches and migraines
· Identifies triggers and patterns
· Captures acute medication usage (and helps ensure it is not being overused)
· Guides treatment decisions
· Helps to evaluate treatment outcomes
· Is helpful to a healthcare provider, but it is invaluable to a migraine sufferer
Canadian Migraine Tracker. Migraine Canada. www.migrainecanada.org
Lagman-Bartolome,M. Lay, C. The Traffic Light of Headache: Simplifying Acute Migraine Management for Physicians and Patients Using the Canadian Headache Society Guidelines. Headache. 2019;59(2):250‐252. doi:10.1111/head.13428
Van den Bergh & Walentynowicz, 2016. Accuracy and bias in retrospective symptom reporting
Current Opinion in Psychiatry. 29(5):302–308, DOI: 10.1097/YCO.0000000000000267
Bigal ME, Lipton RB. Modifiable risk factors for migraine progression. Headache. 2006;46(9):1334-1343. doi:10.1111/j.1526-4610.2006.00577.x