The MIDAS (migraine disability assessment) questionnaire was put together to help you measure the impact your headaches have on your life over the last 3 months and to communicate this more effectively. The best way to this is by counting the numbers of days of your life which are affected by Headaches. You can do this for yourself as follows:

Please complete Questions about ALL your headaches you have had over the last month. Leave the box set to zero if you did not do the activity in the last three months.

For questions 1 and 2, work or school means paid work or education if you are a student at school or college. For Questions 3 and 4, household work means activities such as housework, home repairs and maintenance, shopping as well as caring for children and relatives.

INSTRUCTIONS • Please answers the following questions about ALL your headaches you have had over the last 3 months. Select your answer in the box next to each question. If a single headache affects more than one area of your life (e.g., work and family life) it is counted more than once. Select zero if you did not have the activity in the last 3 months.

  1. (Do not include days you counted in question 1 where you missed work or school.)

  2. (Do not include days you counted in question 3 where you did not do household work.)
What Your Physician will need to know about your headache:

  1. (If a headache lasted more than 1 day, count each day.)

  2. (where 0 = no pain at all and 10 = pain as bad as it can be.)

(Leave this box blank if you do not need a copy.)
This survey was developed by Richard B. Lipton, MD, Professor of Neurology, Albert Einstein College of Medicine, New York, NY, and Walter F. Stewart, MPH, PhD, Associate Professor of Epidemiology, Johns Hopkins University, Baltimore, MD.
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