Keeping a diary of symptoms has long been considered a part of a successful approach to managing migraine headaches. The diary can help identify potential migraine triggers and contributing factors and a description of specific symptoms can help tailor individual therapy.

An article just published in Wired magazine Why tracking your symptoms can make you feel worse, challenges this assumption.

In my early years of practicing headache medicine (yes, “headache medicine” is a formal subspecialty of neurology) I would urge my patients to keep a diary, but they would have all kinds of excuses why they did not. I even developed a phone app, which was easy to use and was loaded with features and educational materials. Everyone always has their phone nearby, so unlike with a paper diary, they would not forget it at home or need a pen, or have it eaten by their dog. Nothing doing. Maybe, one in 10 of my patients attempted to keep a diary. Then, since I also have migraines, I tried using the app and I also failed miserably. My excuses? Forgot, too busy, I know all about my migraines, so what’s the point?

The article in Wired quotes research that suggests that keeping a diary of symptoms can make you feel worse. This seems to be true across different conditions – insomnia, back pain, and also migraine. One possible explanation is that constantly paying attention to sensations in the body we can magnify them. These sensations may send an alarm to the brain, oh-oh, a migraine is starting. This in turn leads to anxiety, activation of the fight-or-flight response and soon a real migraine begins. Actually, when a patient comes in with pages and pages of notes that describe each migraine attack with possible triggers, detailed description of each attack, medications taken and their side effects, I know that this patients will be harder to help.

In case of migraine headaches we do have a very good substitute for a daily diary. It is a Migraine Disability Assessment Scale, or MIDAS, which assesses migraine-related disability over the previous three months. This is a simple 5-question scale that was validated by comparing a daily diary with patient recollection. Surprisingly, the correlation was very strong and the scale gives reliable information. We ask patients to complete MIDAS on every visit. At a glance, it tells us how disabling the migraines are and how aggressive we need to be in starting preventive therapies, such as Botox, drugs, and the new monoclonal antibodies. This score is also helpful for patients who may not remember how disabling the headaches were before they started a particular treatment. It also shows the insurance companies how well an expensive treatment such as Botox works, so that they approve continued therapy.

As far as identifying triggers, most are obvious and patients do not need a diary to tell them that alcohol, lack of sleep, skipping meals, stress, etc. are causing their attacks. Yes, for some patients a diary can identify gluten sensitivity, menstrual cycle, or another trigger that was not obvious, so I would not discourage anyone from keeping a diary. But do it for a few months and if no useful information can be gleaned from it, stop.