KIRBY PLASTIC SURGERY, PLLC
Emily J. Kirby, MD
7250 HAWKINS VIEW DRIVE, SUITE 412 | FORT WORTH, TX 76132 | 817.292.4200 P | 817.292.4205 F
MIGRAINE QUESTIONNAIRE 1. How many migraine headaches do you have per month? 2. How long do your migraine headaches last? 3. What is the name of your neurologist? a. If you do not have a neurologist, who diagnosed your migraine headaches? 4. When were you diagnosed with migraine headaches? 5. Have you ever had any type of head injury? a. What type of injury?
When was the injury?
b. Were your migraine headaches worse after your injury? 6. What medications have you taken for migraine headaches? (circle all that apply) a. Angiotensin-converting enzyme inhibitors (ACE inhibitors) such as losartan (Cozaar), valsartan (Diovan), lisinopril (Prinivil or Zestril) b. Anti-depressants such as amitriptyline (Elavil), clomipramine (Anafranil), doxepin (Silenor), mirtazapine (Remeron), nortriptyline (Pamelor) , protriptyline (Vivactil) c. Anti-epileptic drugs (e.g., gabapentin (Neurontin), topiramate (Topamax), valproic acid (Depakene or Stavzor) d. Beta blockers such as atenolol (Tenormin), metoprolol (Lopressor or Toprol), nadolol (Corgard), propranolol (Inderal), timolol e. Calcium channel blockers such as diltiazem (Cardizem), nifedipine (Procardia), nimodipine (Nimotop), verapamil f. Triptans such as Imitrex, Maxalt, Zomig, Amerge g. Over-the-Counter medications such as Excedrin, Motrin, Advil, Tylenol, Aleve h. Other remedies: 7. Does your medication treat your migraine headaches successfully? 8. Do you have any medication side effects? 9. Where do your migraine headaches typically start? (circle all that apply) a. Right temple vs. Left temple b. Right eyebrow vs. Left eyebrow c. Back of head d. Other area www.KirbyPlasticSurgery.com