Generic Consultation – Migraine

1. About your Health

To help us understand that this treatment is the right option for you, please answer the following questions.

Please state your gender

This refers to your biological gender

Male

Female

What is your date of birth?

Use the calendar to select your date of birth.

Please add your height (in cms)

Your height is important for the prescribers decision.

Please add your current weight (in kgs)

Please make sure to add your current weight. This may affect the prescriber's decision.

Do you have any recent or past medical history of note?

If so, please provide more information

Yes

Do you suffer from any allergies?

If so, please provide more information

Yes

Do you currently take any medication whatsoever?

Please list all your current prescription medication including any medication you buy over the counter.

Yes

Is there a history of medical disorder's within your family?

If so, please provide more information

Yes

Are there any other health/medical details you feel we should know?

If so, please provide more information

Yes

2. About your Condition

To help us understand that this treatment is the right option for you, please answer the following questions.

Is this a repeat prescription?

Yes

Do you experience migraines for more than 10 days a month?

Yes

Do your migraines last less than 4 hours without treatment or last longer than 24 hours?

Yes

Do your migraines follow a broadly similar pattern each time?

Yes

Are you experiencing any of the following along with your migraine?

unilateral motor weakness
double vision
clumsiness or uncoordinated movements
tinnitus (ringing in the ears)
reduced level of consciousness
seizure-like movements (fits)
a recent rash with a headache
headache confined to the back of the head
recent marked deterioration in migraine (duration, severity or frequency of attacks)

Yes

Have you previously been diagnosed with migraines by your GP and have you experienced relief when taking medication containing 'triptans' such as Imigran (Sumatriptan), Rizatriptan (Maxalt), Zomig (Zolmitriptan) ?

Yes

When you have taken a ‘triptan’ medication in the past, within the first few hours of taking it have you experienced sensations such as heaviness, pressure or tightness in the body (especially chest or throat), or have you experienced palpitations, flushing, dizziness, rash, a feeling of weakness, worsening nausea and vomiting or a temporary rise in your blood pressure?

Yes

Are you breastfeeding or pregnant or possibly pregnant?

Yes

Do you have an allergy (hypersensitivity) to Imigran/Sumatriptan, Maxalt/rizatriptan, Zomig/zolmitriptan?

Yes

Have you been diagnosed with any of the following?

Heart disease or heart problems such as narrowing of the arteries (ischaemic heart disease) or chest pains (angina), or have already had a heart attack
Stroke or a mini-stroke (also called a transient ischaemic attack or TIA)
High blood pressure
Coronary Vasospasm (including Prinzmetal’s angina)
Wolff-Parkinson-White Syndrome (a type of abnormal heartbeat)
Peripheral Vascular Disease
Previous Gastrointestinal or Splenic infarction
Ischaemic Colitis
Epilepsy or history of seizures
Liver problems
Kidney problems
Allergy or sensitivity to antibiotics called sulphonamides (e.g. trimethoprim)
Any serious medical condition which may require immediate hospitalisation

Yes

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

If so, please list the medication

Yes

Are you taking any of the following medications?

The migraine medications Ergotamine or Methysergide
Any other ‘triptan’ migraine medication taken within last 24 hours (e.g. naratriptan, rizatriptan, zolmitriptan, almotriptan or eletriptan (NOTE: we advise different types of ‘triptans’ should not be taken within 24 hours of one another)
MAOIs (monoamine oxidase inhibitors) or if you have taken an MAOI in the last 2 weeks (e.g. Mocobemide, Phenelzine, Isocarboxazid and Tranylcypromine)
SSRIs, usually used to treat depression (Selective Serotonin Reuptake Inhibitors – e.g. Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline and Priligy)
SNRIs used to treat depression (Serotonin Noradrenaline Reuptake Inhibitors e.g. Duloxetine, Dapoxetine, Venlafaxine and Mirtazapine)
Reboxetine, Tryptophan or Flupentixol
Lithium
Selegiline
St John’s Wort (Hypericum perforatum)
Cimetidine (for indigestion or stomach ulcers)
Propranolol (beta-blocker)
Any current antibiotics (antibiotic course needs to be completed at least 72 hours before taking a triptan)
Antifungals (e.g. Ketoconazole, Itraconazole)
The combined oral contraceptive pill (not the progesterone only mini pill)

Yes

Is there anything else which you feel we should know about prior to you taking this medication?

Yes

3. The Agreement and Consent

Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

Do you agree to the following?

You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Yes

I agree to the Terms and Conditions and I confirm that I am over 18.
Terms and Conditions

Yes

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