Migraine

Are you aged between 18-65 years old?

Yes

No

Do you have previous history of treatment with Triptans within the last 12 months? (Our clinicians will need to see some record, either via SCR or a prescription repeat slip).

Yes

No

Are you suffering from any of the following symptoms:
• Unilateral/one sided motor weakness
• Double vision
• Clumsy and uncoordinated movements
• Tinnitus, Reduced level of consciousness
• Seizure-like movements
• Recent onset of rash with headache

Yes

No

Have you had any of the following in the past:
• myocardial infarction
• ischaemic heart disease
• angina
• cardiac arrhythmias
• peripheral vascular disease
• heart failure
• stroke or transient ischaemic attack (TIA)
• uncontrolled hypertension
• hepatic or renal impairment
• seizures

Yes

No

Are you pregnant or breastfeeding?

Yes

No

Do you have any of the following cardiovascular risk factors:
• father or brother who had a heart attack or angina before the age of 55 years
• mother or sister who had a heart attack or angina before the age of 65 years
• diabetes
• known high cholesterol
• regularly smoke more than 10 cigarettes a day or use NRT
• obese (BMI >30kg/m2)
• postmenopausal women
• men over 40 years

Yes

No

Are you taking a combined oral contraceptive pill and experiencing worsening of migraine attacks or migraine with aura (may consist of flashing lights, a gleam of light, blurred vision, an odour, the feeling of a breeze, numbness, weakness, or difficulty in speaking)?

Yes

No

Are you currently taking any of the following medicines:
• Ergotamine or derivatives of ergotamine (including methysergide)
• Monoamine Oxidase Inhibitors (MAOIs)
• 5HT1 agonists
• Selective serotonin receptor inhibitors (SSRIs) or Serotonin noradrenaline reuptake inhibitors (SNRIs)
• St John’s Wort
• Prophylactic treatment for migraine

Yes

No

Have you been taking a Monoamine Oxidase Inhibitor (MAOIs) (e.g. Isocarboxazid, Phenelzine, Rasagaline, Selegeline) in the past 2 weeks?

Yes

No

Do you have any of the following allergies or intolerances: galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption, known hypersensitivity to the product or any excipients in the product, known hypersensitivity to sulphonamides

Yes

No

Do you have attacks that last less than 4 hours without treatment?

Yes

No

Have any of your symptom patterns changed? Where recovery between attacks is incomplete or where attacks have become:
• More frequent
• More persistent
• More severe

Yes

No

Do you suffer hemiplegic migraines (temporary weakness in one side of the body), basilar migraines (symptoms incl. double-vision, dizziness, lack of co-ordination) or ophthalmoplegic migraines (involving weakness around the eye muscles)?

Yes

No

Do you have an allergy to sunset yellow?

Yes

No

Are you also taking a potent CYP3A4 inhibitor (ketoconazole, itraconazole, erythromycin, clarithromycin, josamycin and protease inhibitors (ritonavir, indinavir, nelfinavir)?

Yes

No

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Migraine

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