Medical Assessment for Migraine

To help us supply you with the most suitable treatment, please complete this online consultation.

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About You

Are you aged between 18-65?

Yes

We are unable to supply you with treatment. Please consult your GP or doctor.

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Your Symptoms

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

We are unable to supply you with treatment since this medication is not indicated for migraines that cause the symptoms above. Please consult your GP or doctor.

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

Yes

We are unable to supply you with treatment. Please consult your GP or doctor about a suitable migraine treatment plan.

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Do your migraines follow a broadly similar pattern each time?

Yes

We are unable to supply you with treatment. Please consult your GP or doctor.

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

Yes

We are unable to supply you with treatment. Please consult your GP or doctor.

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Your Health

Are you breastfeeding, pregnant or possibly pregnant?

Yes

We are unable to supply you with treatment. Please consult your GP or doctor.

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

Yes

We are unable to supply you with treatment. Please consult your GP or doctor.

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Have you been diagnosed with any of the following?

Heart disease or heart problems such as narrowing of the arteries (ischaemic heart disease)
Chest pains (angina), or have previously 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

We are unable to supply you with treatment. Please consult your GP or doctor.

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

Yes

If you have not been diagnosed with migraines and used triptan medication with success in the past, please contact your GP or doctor.

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If you have taken a ‘triptan’ medication in the past, have you experienced any of the following within the first few hours of taking it?

Heaviness, pressure or tightness in the body (especially chest or throat)
Palpitations
Flushing
Dizziness
Rash
Feelings of weakness
Worsening nausea and vomiting
Temporary rise in blood pressure

Yes

We are unable to supply you with treatment. You should discuss with your GP or doctor the possibility that ‘triptans’ could be causing coronary vasoconstriction or anaphylaxis.

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Your Medication

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

Yes

Are you taking any of the following medications?

The migraine medications Ergotamine or Methysergide
Any other ‘triptan’ migraine medication taken within the last 24 hours (e.g. naratriptan, rizatriptan, zolmitriptan, almotriptan or eletriptan (NOTE: we advise that 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)
Selective Serotonin Reuptake Inhibitors (SSRIs) usually used to treat depression e.g. Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline and Priligy
Serotonin Noradrenaline Reuptake Inhibitors (SNRIs) used to treat depression 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 (except for the progesterone-only mini pill)

Yes

We are unable to supply you with treatment. Please consult your GP or doctor for more information.

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Agreement

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, you start new medication and/or 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
You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber

Yes

You must agree to this before continuing. If you need assistance contact our customer support.

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