Migraine Relief

Please complete your confidential clinical assessment. Evaluated by GMC & GPhC registered healthcare professionals.

About You

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Are you registered with a GP practice in the UK? *

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you? *

(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you).

Do you believe you have the capacity to make decisions about your own healthcare? *

Are you aged between 18-65? *

Symptoms

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

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

Do your migraines follow a broadly similar pattern each time? *

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)

Health

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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)? *

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? *

Are you breastfeeding or pregnant or possibly pregnant? *

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

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

Medication

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

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.Fluconazole, Ketoconazole, Itraconazole)
The combined oral contraceptive pill (not the progesterone only mini pill)

Agreement

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Do you agree to the following? *

I confirm I am over 18 years old.
The medicine ordered is for my sole use only.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
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.
I consent to being contacted by telephone or email should the doctor or pharmacist require further information to assess my order.
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.
You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.

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