IMPERIAL CRS

3 Definitions and additional information: Start Date: Enter the full date (MM/DD/YYYY) and time that the headache started. Check AM or PM to indicate the part of the day. Stop Date: Enter the full date (MM/DD/YYYY) and time that the headache stopped. Check AM or PM to indicate the part of the day. What was the intensity of pain for this headache: Use the facial expression scale (Wong-Baker Faces Pain Rating Scale) to determine how bad the pain was at the worst point for this headache. Ask your child to point to the face that best describes their pain. Enter the level of pain that corresponds to the face. For example, enter "6" if the "hurts even more" face represents how bad the pain was. Nausea: A queasy feeling in the stomach, feeling like you need to throw up. Indicate how severe the nausea was at the worst point during the headache. If no nausea was experienced, check "none". Vomiting: Throwing up; indicate how severe the vomiting was at the worst point during the headache. If no vomiting was experienced, check "none". Sensitivity to light: When light causes a headache to feel worse, people with sensitivity to light will want to be in a dark room or shield their eyes from light. Indicate how severe the sensitivity to light was at the worst point in the headache. If the headache was not affected by light, check "none". Sensitivity to sound: When sound causes a headache to feel worse, people with sensitivity to sound will want to be in a quiet room or get upset when others make noise. Indicate how severe the sensitivity to noise was at the worst point in the headache. If the headache was not affected by noise, check "none". Aura: An aura can cause a variety of visual, sensory, or language symptoms. Some people have auras before they have a migraine, but not everyone does. If aura symptoms occur, check "yes" and answer the two additional questions. If no aura symptoms occur, check "no" and leave the next two questions blank. Some common symptoms of aura are the following: • Visual symptoms: flashes of light or bright spots; zigzag lines or shapes in the field of vision; blind spots or partial loss of vision • Sensory symptoms: tingling or "pins and needles" in the arms or face • Language symptoms: slurred speech, mumbling, not being able to form the right words Did you take non-study medication to treat this headache: If no medication was taken for the headache, check "no" and data collection is complete for this headache. If your child takes medication for the headache, check "yes" and complete the three additional boxes. Mark the box next to each type of medication taken to treat the headache recorded above. Each different medication should be listed on a new row. Do not enter the study medication on this page. Do not record medications taken to prevent headaches (for example, amitriptyline). If you take a medication to treat your headache that is not listed below, write it in the blank space. If more than one dose was taken at different time periods during the same headache, record the dates and times for each. Here is an example for someone that took a Children's Advil (NSAID) twice during the same headache: Medication(s) taken Date taken Times(s) taken a NSAID Acetaminophen Combination Analgesic Triptan Ergotamine / / 9:15 AM; 3:00 PM Here is an example for someone that took a medication that is not listed: Medication(s) taken Date taken Times(s) taken a NSAID Acetaminophen Combination Analgesic Triptan Ergotamine Ubrelvy / / 4:00 pm X 07 07 2020 07 07 2020 X

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