About You

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)

Your Health

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 hospitalization

Your Medication

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, 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 while 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.