Migraine Consultation

Are you aged between 18–65 years old? *

Yes No

Have you previously been diagnosed with migraines by your GP or a Pharmacist? *

Yes No

Have you previously had relief from migraines while taking triptans such as Imigran (Sumatriptan), Rizatriptan (Maxalt), or Zomig (Zolmitriptan)? *

Yes No

Please provide more details

Are you experiencing any of the following?

Headache lasting more than 24 hours
A rash alongside a headache
Unilateral motor weakness (Muscle weakness on one side of the body)
Clumsiness and/or uncoordinated movements
Double vision
Reduced level of consciousness
Tinnitus (Ringing/buzzing in the ears)
Seizure-like movements
Pain in or around the Jaw (Particularly while chewing)

*

Yes No

Please provide more details on the symptoms you are experiencing

Regarding your migraine, please select any of the following that applies *

You can select more than one option

It lasts for more than 72 hours I suffer with more than 6 migraine attacks per month I am NOT able to fully recover between migraine attacks My symptoms have changed or have got worse My first migraine occurred when I was over 50 years old None of the Above

I have been diagnosed with, suffer from or have suffered from *

Please select any of the following that applies (You can select more than one option)

Heart disease or have heart problems such as narrowing of the arteries (ischaemic heart disease) Stroke or a mini-stroke (also called a transient ischaemic attack or TIA) Coronary vasospasm (Prinzmetal angina) Angina (Chest Pains) or have previously had a heart attack Peripheral vascular disease Uncontrolled moderate to severe high blood pressure Liver problems Kidney problems Epilepsy or I have a history of seizures Hemiplegic, Basilar or Ophthalmoplegic migraine None of the Above

Do you suffer from any medical conditions including high cholesterol or have a family history of heart disease? *

Yes No

Please provide more details

Do you smoke more than 10 cigarettes a day or use nicotine substitution therapies? *

Yes No

Are you overweight? *

Yes No

Have you ever had an allergic reaction to Imigran/Sumatriptan, Maxalt/Rizatriptan, Zomig/Zolmitriptan? Or have any other allergies we should be aware of? *

Yes No

Please provide more details on ALL of your allergies

Are you pregnant, possibly pregnant, or breastfeeding? *

Answer No if you are Male

Yes No

Are you currently taking or have recently finished taking (in the last month) any OTHER medication, whether prescribed or non-prescribed including over-the-counter, herbal, or recreational drugs? *

Yes No

Please provide more details

Is there any other medical or non-medical information we should be aware of? *

Yes No

Please provide more details

Would you like us to inform your GP of any treatment you receive from us? *

Yes No

Before you continue

Please read the following statements:

I confirm these questions have been answered truthfully and accurately. I understand that any incorrect information may be detrimental to my health
I confirm the medication is for my personal use only and I should inform my GP of any treatment I receive from Pharmacy
I confirm I will take the medication as prescribed or directed for its intended use and if I am not requesting the starting dose for that medication, I have taken the medication previously on that dose and without any side effects
I confirm I have tried other treatments without relief before requesting triptan medication
I have or will read the patient information leaflet and I will contact a medical professional if I have any questions or experience any side effects while taking the medication
All information provided will be handled in the strictest confidence in line with GDPR. I am happy for Pharmacy to collect and use the information I provide for the purposes of providing treatment for my medical condition
I am happy to be treated by the prescribers and health care professionals at Pharmacy and the final decision on whether to provide treatment will be with the prescriber and or pharmacist
I understand that I should NOT use this medication to treat migraine preventatively or pre-emptively
I understand that triptan medications should be used with caution if I am taking Combined Oral Contraceptive and should NOT be taken alongside certain antidepressants such as SSRIs or MAOIs as this would be VERY dangerous

I agree to all of the above statements