UTI questionaire

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Acute Migraine questionnaire

Persistent or worsening headaches may signal a serious condition. Headaches that are new, progressively worsening, daily, worse in the morning, wake you from sleep, or are associated with vision changes, weakness, numbness, speech difficulty, seizures, persistent vomiting, or cognitive or personality changes require urgent in-person medical evaluation.

I have read the above information and wish to move forward

I have read the above information and I do not wish to continue

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Your visit has been canceled

You chose not to proceed with this evaluation. No further action is required.

If you change your mind or need care later, you’re welcome to start a new visit at any time.

Find another visit type

Reproductive Health Screening

We ask these questions to ensure that any medication prescribed is safe based on your biological sex and pregnancy status.

What was your sex assigned at birth?

Male

Female

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Reproductive Health Screening

Are you currently pregnant or breastfeeding?

Yes

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Reproductive Health Screening

I understand that the medication prescribed to me by my healthcare provider may not be safe to take during pregnancy. I acknowledge that taking this medication while pregnant could pose risks to my health and the health of a developing fetus.

I agree to take necessary precautions to avoid becoming pregnant while using this medication, including the use of effective contraception methods as discussed with my healthcare provider.

I understand that I should stop taking this medication before attempting to become pregnant. I agree to consult with my healthcare provider prior to discontinuing the medication and before planning a pregnancy to ensure my safety and well-being.

By selecting below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.

I have read and understand the consent and wish to proceed

I do NOT wish to proceed

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Have you previously been diagnosed with migraine by a healthcare professional?

Yes

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Are your headaches consistent with your usual migraine pattern?

Yes my symptoms are typical for my known migraines

No, this headache feels different

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Have you ever been told you have hemiplegic migraine or migraine with brainstem aura?

Yes

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When did this current headache begin?

Less than 24 hours ago

1–3 days ago

More than 72 hours ago

No current symptoms, I’m preparing for my next episode

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Where is the pain located?

Unilateral (one side)

Bilateral (both sides)

Frontal (forehead)

Occipital (back of head)

Other

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Do your migraines start with an aura (visual, sensory, or speech symptoms before the headache)

Aura only

Aura followed by headache

No aura

I am unsure

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Which of these commonly trigger your migraines?

Stress or anxiety

Sleep disturbances

Hormonal changes (e.g., menstrual cycle)

Dietary factors (e.g., caffeine, alcohol, certain foods)Dehydration

Bright lights or strong odors

Weather changes

Other

Continue

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Submit

How often do you use acute migraine medications per month?

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Let's determine the best treatment option for you. Which acute (abortive) medications have you used for your migraines?

Have you tried first line treatment for migraines such as NSAIDs such as ibuprofen, naproxen, or diclofenac?

I have not tried these OR I have tried these and they work well

I have tried these and they’re not effective or they cause side effects

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Do you have a history of kidney disease, stroke, TIA, heart disease, prior heart attack or uncontrolled hypertension.

Yes

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Have you tried second line treatment for migraines called Triptans such as sumatriptan, rizatriptan, eletriptan, or zolmitriptan)

I have not tried these OR I have tried these and they work well

I have tried these and they’re not effective or they cause side effects

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Do you have a history of Raynaud’s phenomenon, stroke, TIA, heart disease, prior heart attack or uncontrolled hypertension.

Yes

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Have you tried third line treatment for migraines called gepants such as ubrogepant, rimegepant, zavegepant?

I have not tried these OR I have tried these and they work well

I have tried these and they’re not effective or they cause side effects

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Do you have liver disease, or are you taking medications that strongly affect how your liver processes drugs (such as clarithromycin, itraconazole, or ritonavir)?

Yes

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Do you vomit or have severe nausea early in your migraine attacks?

Yes, frequently

Sometimes

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Do you currently take any antidepressant medications, including SSRIs or SNRIs?
Examples include sertraline (Zoloft), fluoxetine (Prozac), escitalopram (Lexapro), paroxetine (Paxil), citalopram (Celexa), venlafaxine (Effexor), duloxetine (Cymbalta), or desvenlafaxine (Pristiq)

Yes

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Common migraine medications can increase serotonin levels in the body. When these medications are used together with antidepressants such as SSRIs or SNRIs, there is a very low but possible risk of a rare condition called serotonin syndrome. Symptoms may include agitation, restlessness, confusion, tremor, muscle stiffness or twitching, rapid heart rate, changes in blood pressure, increased sweating, flushing, fever, nausea, or diarrhea. Most cases are mild, and serotonin syndrome is uncommon when migraine medications are taken as prescribed. If concerning symptoms occur, prompt medical evaluation is important.

I understand and wish to continue

I understand and wish to avoid this class of medication

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Consent (Truthfulness):

Please attest to the following confirming that all information you have provided to us is true and complete.

Consent: I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor.

I have read and understand the consent and wish to proceed

I do NOT wish to proceed (End visit)

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Consent for Acute Migraine Treatment

You are requesting treatment for acute migraine attacks. Migraine is a neurologic condition that can cause recurrent headaches and may be associated with symptoms such as nausea, vomiting, sensitivity to light or sound, and visual disturbances. Acute migraine treatment is intended to relieve symptoms during an active migraine attack and may include non-opioid pain relievers, triptans, CGRP-targeted therapies (including gepants or intranasal medications), and anti-nausea medications. These treatments are not intended to prevent future migraines.

Potential Benefits

Relief of migraine pain during an active attack
Reduced severity and duration of migraine symptoms
Improved ability to function during daily activities
Reduced need for emergency or urgent care visits

Potential Side Effects

While acute migraine medications are commonly used and often effective, they can cause side effects. In rare cases, medications may result in emergency room visits, hospitalization, or serious medical complications.

Common Side Effects (may vary by medication class):

Nausea or upset stomach
Drowsiness or fatigue
Dizziness or lightheadedness
Dry mouth
Constipation or diarrhea
Nasal irritation or injection-site reactions (with certain formulations)

Serious or Less Common Side Effects:

Chest pain, shortness of breath, or changes in blood pressure
Allergic reactions (rash, itching, swelling, difficulty breathing)
Worsening headache or medication-overuse headache
Liver function abnormalities

Risks and Considerations

Cardiovascular Risk: Certain acute migraine medications (such as triptans) are not appropriate for individuals with a history of stroke, heart disease, uncontrolled hypertension, or vascular conditions. Your medical history and questionnaire responses are reviewed to reduce this risk.
Medication Interactions: Some acute migraine treatments interact with antidepressants, antifungals, antibiotics, antivirals, or seizure medications. You must disclose all medications and supplements you are currently taking.
Liver or Kidney Disease: Certain acute treatments may not be appropriate if you have liver or kidney disease, and alternative medications may be recommended.
Pregnancy Considerations: Some acute migraine medications are not safe during pregnancy or while trying to conceive.
Medication-Overuse Headache: Frequent use of acute migraine medications can worsen headaches over time. If this risk is identified, treatment adjustments or in-person evaluation may be recommended.

Your response to treatment and any side effects will be monitored through follow-up visits and secure messaging. You may be asked to report migraine severity, symptom relief, and medication effectiveness. Treatment may be adjusted or discontinued for safety reasons. You should seek urgent in-person or emergency medical care if you experience new neurologic symptoms, severe chest pain, fainting, or signs of an allergic reaction.

I acknowledge that I have reviewed the potential benefits, risks, and side effects of acute migraine treatment medications. I understand that these treatments are intended for symptom relief during migraine attacks and do not prevent future migraines. I understand that no treatment guarantees complete relief and that medication selection is based on my medical history and responses. I agree to provide accurate health information and to participate in appropriate monitoring and follow-up

I have read and understand the consent and wish to proceed

I do NOT wish to proceed

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We’re sorry — we’re not able to treat this case online

Based on the information you provided, this visit type requires in-person medical evaluation for safe and appropriate care.

What you were seeking help for:

• Acute Migraine

Why this happens

Some symptoms, medical history details, or risk factors mean a condition can’t be safely managed through telemedicine. A licensed provider must examine you in person to ensure the right diagnosis and treatment.

What to do next

Please visit a local urgent care, primary care clinic, or emergency department if your symptoms worsen.

Find another visit type

Cookie Settings

Acute Migraine questionnaire

Your visit has been canceled

Medical background

Reproductive Health Screening

Reproductive Health Screening

Reproductive Health Screening

Have you previously been diagnosed with migraine by a healthcare professional?

Are your headaches consistent with your usual migraine pattern?

Have you ever been told you have hemiplegic migraine or migraine with brainstem aura?

Have you experienced any of the following symptoms with this headache or in the past 3 months? (Select all that apply.)

When did this current headache begin?

Where is the pain located?

Where is the pain located?

Do your migraines start with an aura (visual, sensory, or speech symptoms before the headache)

Which of these commonly trigger your migraines?

Which of these commonly trigger your migraines?

How often do you use acute migraine medications per month?

Let's determine the best treatment option for you. Which acute (abortive) medications have you used for your migraines?

Have you tried first line treatment for migraines such as NSAIDs such as ibuprofen, naproxen, or diclofenac?

Do you have a history of kidney disease, stroke, TIA, heart disease, prior heart attack or uncontrolled hypertension.

Have you tried second line treatment for migraines called Triptans such as sumatriptan, rizatriptan, eletriptan, or zolmitriptan)

Do you have a history of Raynaud’s phenomenon, stroke, TIA, heart disease, prior heart attack or uncontrolled hypertension.

Have you tried third line treatment for migraines called gepants such as ubrogepant, rimegepant, zavegepant?

Do you have liver disease, or are you taking medications that strongly affect how your liver processes drugs (such as clarithromycin, itraconazole, or ritonavir)?

Do you vomit or have severe nausea early in your migraine attacks?

Do you currently take any antidepressant medications, including SSRIs or SNRIs?
Examples include sertraline (Zoloft), fluoxetine (Prozac), escitalopram (Lexapro), paroxetine (Paxil), citalopram (Celexa), venlafaxine (Effexor), duloxetine (Cymbalta), or desvenlafaxine (Pristiq)

Additional Information

Consent (Truthfulness):

Consent for Acute Migraine Treatment

We’re sorry — we’re not able to treat this case online

What you were seeking help for:

Why this happens

What to do next

MAIN FORM

Acute Migraine questionnaire​​​​​​​​​​​​​​

Have you experienced any of the following symptoms with this headache or in the past 3 months? (Select all that apply.)

Where is the pain located?

Which of these commonly trigger your migraines?

Which of these commonly trigger your migraines?

What you were seeking help for:

Why this happens

MAIN FORM

Acute Migraine questionnaire