Migraine

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

Are you experiencing any of the following?:

• Headache lasting more than 24 hours
• A rash with a headache
• Unilateral motor weakness (Muscles weakness on one side of the body)
• Clumsy and 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)

Regarding your migraine…

• Does it last for more than 72 hours?
• Do you suffer more than 6 migraine attacks per month?
• Are you NOT able to fully recover between migraine attacks?
• Have your symptoms changed or have got worse?
• Did your first migraine occur when you were over 50 years old (Not relevant if you are below 50 years old)

Have you been diagnosed with any of the following?:

• Heart disease or 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)
• Chest pains (angina), or have previously had a heart attack
• Peripheral vascular disease
• Uncontrolled moderate to severe high blood pressure
• Liver problems
• Kidney problems
• Epilepsy or history of seizures
• Hemiplegic, Basilar or Ophthalmoplegic migraine

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

• I confirm the above 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 e Shop 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 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 e Shop 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 e Shop 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 have read and accept the terms & conditions and privacy policy