Migraine consultation

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Name *

First

Last

Date of birth *

Email *

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Have you had your migraines diagnosed by a doctor? *

Have your migraines changed since you last saw your doctor? *

Can you tell us how they have changed? Select one or more answers *

More frequent
More painful
New symptoms
Started experiencing aura
Pain in new location
Medication less effective
Other

Please can you provide more detail on how they have changed? *

Please select the symptoms that you experience: Select one or more answers *

Headache
Nausea
Vomiting
Sensitivity to light
Sensitivity to sound
Aura or Visual disturbance (Seeing flickering lights, spots or zigzag lines in your vision)
Other

Please can you tell us when you first started experiencing migraines? Select one answer *

As a child <12 years
As an adolescent 12-18
As an adult 18 – 30
Over the age of 50

We’re sorry, but there are no suitable treatments for you.

The safety and well-being of our patients is our number one priority, and based on your answers, we can’t recommend any of our treatment options. We know this is both frustrating and disappointing, but we want to make sure that we’re putting your health first and that you find the right care.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Have you experienced any of the following?

Pain or discomfort in the jaw that typically occurs while chewing?
Intense 10/10 headache of explosive onset (feels like you have been hit on the back of the head)?
Have recently had an injury to the head?
Any changes to your thinking, behaviour or personality?
Redness in just one eye?

Migraine Red flag *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you have any of the following conditions?

Problems with your heart
Epilepsy or seizures
Stroke or TIA (mini-stroke)
Liver or kidney problems
Lupus

Medical CI *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

How often do you experience migraines? Select one answer *

This is my first migraine
Once a month or less
Two to four times a month
More than once a week

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do any of the following apply to you?

You have HIV or are immunosuppressed
You have had or do have cancer
Blood in the urine
Chest pain
Difficulty breathing

First migraine red flag *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Can you tell us how you normally manage your migraine headaches? Select one or more answers *

Painkillers such as paracetamol or ibuprofen
Triptan medications such as sumatriptan (Imigran), rizatriptan (Maxalt), zolmitriptan (Zomig)
Anti-sickness medications such as Buccastem M
Other

Please can you tell us what treatments you currently use or have used to manage your migraines? *

Have you noticed any of the following:

Headache associated with bending or coughing?
Significant or prolonged physical weakness?
Headache causing you to wake from sleep?
Headache worsening over weeks or longer?

Worsening headaches *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you take any of the following medicines:

Combined oral contraceptive pill
Ergotamine or methylsergide
MAOIs (e.g. moclobemide or selegiline)
SSRIs (e.g. citalopram, fluoxetine or sertraline) or other medicines for depression
Lithium
St. John’s Wort (a herbal remedy)
Cimetidine (for indigestion or stomach ulcers)
A quinolone antibiotic (e.g. ciprofloxacin)

Medicine red flag *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Are you aged over 60? *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Please select your treatments *

Sumatriptan, Almotriptan or Zolmitriptan
Zydura
Migraleve or products containing paracetamol and codeine

Have you taken sumatriptan, almotriptan or rizatriptan before *

Did you experience any side effects from the sumatriptan, almotriptan or rizatriptan? *

Please tell us what side effects you experienced with sumatriptan, almotriptan or rizatriptan *

Please specify if you have or suffered with:

Myocardial infarction or heart attack
Ischaemic heart disease
Coronary vasospasm ( Prinzmetal’s angina)
Peripheral vascular disease
Cerebrovascular event i.e a stroke
Transient ischemic attack (TIA)
Kidney or liver disease
Moderate or severe hypertension (high blood pressure)
Mild uncontrolled hypertension (high blood pressure)

Triptan condition CI

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you take any of the following:

Ergotamine, or derivatives of ergotamine (including methysergide)
Any triptan/5-hydroxytryptamine1 (5-HT1) receptor agonist
Monoamine oxidase inhibitors (MAOIs)

Triptan medicine CI

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Have you taken Migraleve before? *

Did you experience any side effects from the Migraleve? *

Please tell us what side effects you experienced with Migraleve? *

Do any of the following apply:

You are allergic to paracetamol, dihydrocodeine, or codeine
You have liver or kidney disease, including alcoholic liver disease
You have bowel problems including blockage of your bowel
You have had an operation to remove your gall bladder
You have been told by your doctor that you have an intolerance to some sugars
You know that you metabolise codeine very rapidly into morphine
You suffer from breathing difficulties
You suffer from raised pressure in your head (raised intracranial pressure) or convulsions
You are suffering from diarrhoea caused by poisoning or have watery, severe diarrhoea which may be bloody

Migraleve condition CI *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you take any of the following medicines:

Metoclopramide or domperidone (for nausea)
Cholestyramine (to lower cholesterol)
Medicines called MAOIs (Monoamine oxidase inhibitors, e.g. selegiline)
Medicines that prevent blood clotting (e.g. warfarin)
Substances that make you drowsy (e.g. sedatives, antidepressants or alcohol)
Other medicines containing paracetamol, codeine or dihydrocodeine
Medicines such as atropine, procyclidine or hyoscine which are used to treat problems with gut movements
Antihistamines which may be used in cough/cold remedies and anti-allergy products
Quinidine or mexiletine (used to regulate heart rhythm)
Cimetidine (used to treat stomach ulcers)
Naltrexone (used in the treatment of drug dependence)
Medicines known as antimuscarinics:
- Atropine (used for some eye or bowel conditions).
- Tricyclic antidepressants (e.g. amitriptyline).

Migraleve medicine CI *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you agree to stop taking this medicine and seek immediate medical advice if you experience any of the following symptoms:

Slow or shallow breathing
Confusion
Sleepiness
Small pupils
Feeling or being sick
Constipation
Lack of appetite

Migraleve side effect *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you understand that:

The maximum dose is 8 tablets (two Migraleve Pink and six Migraleve Yellow) in 24 hours
You should not take more than 2 Migraleve Pink tablets in 24 hours
This medicine should not be taken for more than 3 days consecutively
You should not take this medicine with any other medicine containing paracetamol, codeine, dihydrocodeine or sedatives
This medication can make you sleepy and you should not drive or undertake activities that require your concentration while using this treatment

Migraleve dose confirmation *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Have you taken Zydura before? *

Did you experience any side effects from the Zydura? *

Please tell us what side effects you experienced with Zydura? *

Do you take any of the following medications?

Itraconazole and clarithromycin (medicines used to treat fungal or bacterial infections)
Ritonavir and efavirenz (medicines to treat HIV infections)
Bosentan (a medicine used to treat high blood pressure)
St. John’s wort (a herbal remedy used to treat depression)
Phenobarbital (a medicine used to treat epilepsy)
Rifampicin (a medicine used to treat tuberculosis)
Modafinil (a medicine used to treat narcolepsy)
Fluconazole and erythromycin (medicines used to treat fungal or bacterial infections)
Diltiazem, quinidine, and verapamil (medicines used to treat an abnormal heart rhythm, chest pain (angina) or high blood pressure)
Cyclosporin (a medicine used to prevent organ rejection after an organ transplant)

Zydura medicine CI *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

What is your biological sex? *

Male
Female

Are you pregnant, breastfeeding, or trying for a baby? *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you have any other medical conditions not already mentioned? *

Please tell us about any medical conditions not previously mentioned *

Are you taking any other medications that has not already mentioned? *

Please share details of any other medical conditions you have and any medications you are currently taking. Be sure to include the name of each medication, the dosage, and how long you’ve been using it.

Other medication *

Do you have any other allergies that you have not previously mentioned? *

Please give us more details on these allergies *

Do you agree and consent to the following?

I am at least 18 years old and live in the UK.
I have the capacity to make decisions about your own healthcare
I shall be the sole user of any medication offered to me through this service.
I confirm all answers are provided by me and are truthful.
You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
If prescribed a treatment, I will read the Patient Information Leaflet (PIL) that will be provided.
If prescribed a treatment, I will inform my GP of my treatment and contact them if I have any side effects associated with the treatment.
You agree to our terms and conditions, privacy policy and acceptable use policy
You are aware you will be subject to a soft check to validate your identity using LexisNexis.

Checkboxes *

I agree to the statements and give my consent for any treatment provided.

Are you registered with a GP in the UK?

(Optional) Do you consent to us accessing your NHS Summary Care Record (the medical details held by your GP) or requesting further information on your medical history from your GP?

Summary care records

I consent

(Optional) Do you give us consent to write to your GP to share information of this supply and any information we hold about you?

Send information to GP

I consent

Product Category

Important

We review all orders to ensure they’re the best treatment we can offer you. If what you ordered is unsuitable, we will refund part or all of your order.

If we decide what you ordered is unsafe for you, given the other information you provided, we won’t issue any treatment. However, we may call you and suggest alternatives.

Migraine consultation

Do you agree and consent to the following?

Conditions

Treatments

Care and policies