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Patient {{$iPatientNo}}

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A multicentre, retrospective, observational survey study to analyse the role of Propranolol in adult female patients with migraine

Inclusion criteria:

Adult female patients of migraine headache, & prescribed Propranolol or Propranolol + Flunarizine as treatment or prophylaxis (monotherapy or adjunctive therapy)

DEMOGRAPHIC DATA

Initials*

Serial No.*

Age (yr) *

Occupation *

Weight (kgs)*

Marital status *

Single Married

Name of clinic/hospital*

Date of data collection*

DETAILS OF DIAGNOSIS AND TREATMENT

Comorbidities, if Yes

Conditions	YES or NO	Years	Months
Insomnia
Major depressive disorder
Hypertension
Mention others if any

Place in therapy *

Use of Propranolol in this patient as:

First- line option 1^st add-on 2^nd add-on 3^rd add-on

Total daily dose of Propranolol*

40mg 80mg 120mg 160mg 240mg 320mg

Total daily dose of Propranolol + Flunarizine*

40mg/ 5mg 40mg/ 10mg

Reasons for choosing Propranolol*

Concomitant medication, if any

Sr. No	Generic Name	Route & Dose	Duration
1
2
3
4
5

Any other comments