Pain RTS Script

How would you start the consultation?

Hello my name is Ansali and I'm one of the pharmacists here today.

How can I help you today?

Can I ask who I'm speaking to and if this is for you or someone else?

Would you like to go somewhere private like the consultation room to discuss this?

What question do you ask for S (Site) and what does unilateral/bilateral indicate?

"Where exactly is the pain? Is it on one side of your head, both sides, around your eye?"

- Unilateral = migraine/cluster; Bilateral = tension

What question do you ask for O (Onset) and what does sudden indicate?

"When did this headache start? Was it gradual over hours, or did it come on suddenly within seconds or minutes?" Sudden = thunderclap (red flag - SAH)

What question do you ask for C (Character) and what do the answers mean?

"How would you describe the pain? Is it throbbing/pulsating, a tight band/pressure, stabbing/sharp, or dull/aching?" Throbbing = migraine; Tight band = tension; Stabbing = cluster

What question do you ask for R (Radiation) and what does cluster radiate to?

"Does the pain stay in one place, or does it move anywhere else - like down into your neck, shoulder, jaw, or behind your eye?" Cluster radiates to eye/face

What question do you ask for A (Associated symptoms) and what do the answers mean?

"Along with the headache, do you have any other symptoms? For example: nausea or vomiting? Sensitivity to light or noise? A watery or red eye? A runny or blocked nose on one side? Any weakness, numbness, or trouble speaking?" Nausea/photo/phono = migraine; Red/watery eye = cluster; Neuro symptoms = red flag

What question do you ask for T (Time) and what are the durations?

"How long does each headache last when you don't take anything? Is it constant or does it come and go? Do you get them at a particular time of day or night?" Migraine 4-72h; Tension 30min-7d; Cluster 15-180min (often at night)

What question do you ask for E (Exacerbating/Relieving factors) and what do the answers mean?

"What makes the headache better or worse? For example, does normal physical activity like walking or climbing stairs make it worse? Does lying down help or make it worse? Have you tried any painkillers - and did they help?" Activity worsens = migraine; Restlessness/eased by movement = cluster

What question do you ask for the second S (Severity) and what does severity indicate?

"On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain you can imagine, how bad is this headache right now? At its worst?" Mild/moderate = tension; Severe/very severe = migraine/cluster

What question do you ask for Ideas?

"What do you think might be causing these headaches?"

What question do you ask for Concerns?

"Is there anything in particular that you're worried about?"

What question do you ask for Expectations?

"What were you hoping I could do for you today?"

What are the red flag questions you must ask?

Did this reach its worst within 5 minutes? Is this your first headache like this? And are you over 50? Does it get worse when you stand up? Does coughing or bending make it worse? Any head injury in last 3 months? Any history of cancer or immune problems? Any weakness, slurred speech, or vision loss? Any fever or neck stiffness? Is your eye red? Are your temples tender to touch?

What do you say after red flag questions?

"Thank you for telling me all about the headache itself. Now I need to ask you some questions about your general health and any medicines you take, to make sure whatever we recommend is safe for you."

What question do you ask for full medical history?

"Do you have any long-term medical conditions?"

What questions do you ask for drug history?

"Are you taking any prescribed medicines from your doctor? If so, what are they, what strength, and how often do you take them?" "Do you take any over-the-counter medicines regularly?" "Do you take any herbal remedies?" "Have you taken anything for this headache already today? What and how much?"

What question do you ask for allergy status?

Just to check, do you have any allergies?

What question do you ask about pregnancy/breastfeeding?

"Just to be completely safe - is there any chance you could be pregnant, are you trying to conceive, or are you currently breastfeeding?"

What action if patient is pregnant?

Paracetamol = first line; Avoid NSAIDs (especially 3rd trimester); Avoid triptans (licensed OTC contraindicated); Refer to GP

What action if patient is breastfeeding?

Paracetamol and ibuprofen = safe; Sumatriptan = low levels in milk, but OTC licence often excludes; Check PIL; Refer to Breastfeeding Network

What do you say when identifying the problem?

"Based on everything you've told me, this meets the clinical criteria for… Explain the causes"

What do you say to involve patient preference?

"These are the options available to you, which one would you prefer?"

Why not recommend ibuprofen or aspirin for severe migraine?

"I am not recommending ibuprofen or aspirin because your migraine is already severe and paracetamol didn't work - NSAIDs are less effective once a migraine is established, though they can help some people if taken very early."

Why not recommend codeine or opioids for migraine?

"I am not recommending codeine or any opioid products. They can make nausea worse, slow down your stomach so the medicine isn't absorbed properly, and lead to medication-overuse headache if used too often."

What general lifestyle advice do you give?

Stay hydrated. Keep regular meal and sleep times. Gentle exercise like yoga between attacks can help reduce frequency.

What advice do you give during a migraine?

Lie down in a dark, quiet room. Apply a cold compress or ice pack to your forehead. Avoid screens and bright lights.

Where do you signpost for more resources?

The Migraine Trust website (migrainetrust.org) has excellent resources, including diary templates and trigger management advice.

What do you ask to check for questions?

So do you have any questions for me?

When do you tell the patient to go to A&E or call 999?

Go to A&E or call 999 immediately if: the headache becomes sudden and explosive within seconds, you get weakness on one side, slurred speech, confusion, or fever with a stiff neck.

When do you tell the patient to see GP within a day or two?

See your GP within a day or two if: the headache keeps getting worse over several days.

When do you tell the patient to make a routine GP appointment?

Make a routine GP appointment if you're having more than 4 migraines a month.

What do you say about treatment side effects?

Read from the patient information leaflet

What do you say to check understanding before finishing?

Just before I finish, did you understand everything? I know it was a lot to take in. Do you have any concerns following the plan at all?

What do you say to close the consultation?

That's it then, take care.