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Medical Assessment

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About You
Are you aged between 18-65?
We are unable to supply you with treatment. Please consult your GP.
Please complete this question.
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)
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.
Please complete this question.
Do you experience migraines for more than 10 days a month?
We are unable to supply you with treatment. You should consider a migraine treatment plan with your GP. Please consult your GP.
Please complete this question.
Do your migraines follow a broadly similar pattern each time?
We are unable to supply you with treatment. Please consult your GP.
Please complete this question.
Do your migraines last less than 4 hours without treatment or last longer than 24 hours?
We are unable to supply you with treatment. Please consult your GP.
Please complete this question.
Your Health
Are you breastfeeding or pregnant or possibly pregnant?
We are unable to supply you with treatment. Please consult your GP.
Please complete this question.
Do you have an allergy (hypersensitivity) to Imigran/Sumatriptan, Maxalt/rizatriptan, Zomig/zolmitriptan?
We are unable to supply you with treatment. Please consult your GP.
Please complete this question.
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
We are unable to supply you with treatment. Please consult your GP.
Please complete this question.
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) ?
If you have not been diagnosed with migraines and used triptan medication with success before contact your GP.
Please complete this question.
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?
We are unable to supply you with treatment. You should discuss with your GP the possibility that ‘triptans’ could be causing coronary vasoconstriction or anaphylaxis
Please complete this question.
Your Medication
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. Ketoconazole, Itraconazole)
  • The combined oral contraceptive pill (not the progesterone only mini pill)
We are unable to supply you with treatment. Please consult your GP.
Please complete this question.
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
  • 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.
You must agree to this before continuing. If you need assistance contact customer support.
Please complete this question.
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Ana Carolina Osorio De Faria Goncalves
To find a treatment suitable for you, we just need you to answer a few questions.
Ana Carolina Goncalves
Superintendent Pharmacist
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Need help?

If you need help with this medical assessment, contact our helpline:

0207 112 9014

or email us:

help@pharmica.co.uk
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