Brain Mechanisms of Vagus Nerve Stimulation and Stress Reduction Training for Migraine
Phase: NA
Conditions: Migraine
Sponsor: Massachusetts General Hospital

 
 
 
 
 
Vagus Nerve Stimulation and Stress Reduction 
Training for Migraine 
NCT03592329 
Document date: November 25th, 2024 
 
 

 
Clinical Intervention Study​
Protocol  
Study Product Guidelines and Considerations​
2 of 68​Version 3.1 
​
​November 25th, 2024 

FULL PROTOCOL TITLE 
Boosting mind-body mechanisms and outcomes for chronic pain 
A randomized, placebo-controlled longitudinal trial evaluating the effects of combined 
Respiratory-gated Auricular Vagal Afferent Nerve Stimulation (RAVANS) and Mindfulness 
Meditation (MM) in Migraine patients. 
 
Study Chairman or Principal Investigator:   
Vitaly Napadow, PhD, LAc 
Massachusetts General Hospital 
Harvard Medical School 
 
Supported by: ​
The National Center for Complementary and Integrative Health  
P01 AT009965-01 
 
Study Intervention Provided by:  
Martinos Center for Biomedical Imaging, Department of Radiology,                                    
Massachusetts General Hospital, Harvard Medical School 
Cambridge Health Alliance (CHA), Center for Mindfulness and Compassion 
 
Sponsor of IND (IDE):  
Marco Loggia, PhD 
Massachusetts General Hospital 
Harvard Medical School 
IND#142546 for the use of [11C] PBR28 in PET/MR imaging  
​
 
 
 
 
Study Product Guidelines and Considerations​
3 of 68​Version 3.1 
​
​November 25th, 2024 

Tool Revision History 
Version Number: 1.0 
Version Date: October 8, 2018 
Summary of Revisions Made: first draft 
Version Number: 1.2 
Version Date: December 23, 2018 
Summary of Revisions Made: 
-​
Updates based on OCRA edits to randomization strategy 
Version Number: 1.3 
Version Date: June 1, 2019 
Summary of Revisions Made: 
-​
Study roster section was updated to include two new research coordinators  
-​
Following recommendations from our EAB the inclusion and exclusion criteria for both 
healthy controls and migraine patients have been modified  
-​
RAVANS tVNS stimulation parameters have been updated   
-​
Consenting procedures have been modified to include a nurse practitioner or an MD in 
order to follow Partners IRB recommendations.  
-​
The Education Control protocol has been modified to better match the duration and 
activities from the MBSR intervention  
-​
A new activity (ambulatory ECG and actigraphy measurement) has been added to 
provide exploratory data on heart rate variability and motor activity during the 
intervention  
-​
The list of psychometric assessments has been modified according to EAB 
recommendations  
-​
A new task (Quantitative Sensory Testing) has been added to the Autonomic Assessment 
session to provide an additional measure of pain processing in study subjects  
-​
Information about PBR affinity testing for PET imaging has been added  
-​
StudyTRAX will be the electronic data capture system used in the study instead of 
RedCAP to follow with FDA regulations (21 CFR Part 11)  
 
Version Number: 1.4 
Version Date: August 2, 2019 
Summary of Revisions Made: 
-​
Incorporated changes from OCRA,Westat, and NCCIH. 
-​
Updated participant randomization to occur before the baseline assessment. 
-​
The Baseline visits have been changed from 2 weeks to 3 weeks.  
-​
PET-MR criteria has been separated from the general exclusion and inclusion criteria. 
-​
Added a more detailed explanation of what happens when participants are no longer 
eligible for the A-line after genotype testing.  
Study Product Guidelines and Considerations​
4 of 68​Version 3.1 
​
​November 25th, 2024 

-​
Study roster section was updated to include a phone number for new study staff and 
removed staff no longer involved in the study.  
-​
The inclusion and exclusion criteria for both healthy controls and migraine patients have 
been modified to reflect IRB changes.  
-​
Adherence for groups and booster sessions has been updated.  
-​
Added a daily diary eligibility procedure. 
-​
Added the Rally website as an additional resource for recruitment. 
-​
Updated welcome letter details. 
Version Number: 1.5 
Version Date: August 22, 2019 
Summary of Revisions Made: 
-​
Included safety reporting process specific to an IND-regulated study.  
-​
Clarified MD/NP procedures at screening. 
-​
Updated study staff personnel.  
Version Number: 1.6 
Version Date: September 5, 2019 
Summary of Revisions Made: 
-​
Updated the age of inclusion criteria for healthy volunteers to match the inclusion criteria 
of migraine subjects. 
-​
Updated information about procedures of the QST session. 
-​
The forehead stimulation procedure in fMRI assessments has been clarified. 
-​
A breath-hold task has been added to the fMRI visits as well as a section on breath-hold 
risks and a new exclusion criterium for the study related with this test. 
-​
A toxicology screening has been added to the PET-MR visit. 
-​
A saliva draw for the genotype test during screening has been added.  
-​
Added nature-based questionnaires to baseline and post-treatment visits. 
-​
Removed if the participant would prefer consent of MD or NP to correspond with IRB 
protocol updates.  
-​
Minor grammar and rewording edits.  
Version Number: 1.7 
Version Date: November 26, 2019 
Summary of Revisions Made: 
-​
Exclusion criteria have been updated following FDA recommendation. 
-​
Details about the fMRI session have been clarified.  
-​
An exploratory heartbeat detection task has been added to the procedures of the first and 
last booster sessions.  
-​
An exploratory Motion Coherency Test (MCT) has been added to the PET/MR visit. 
-​
PET blood draw procedure specifications have been added.  
Study Product Guidelines and Considerations​
5 of 68​Version 3.1 
​
​November 25th, 2024 

-​
QST procedures have been clarified.  
-​
Questions about pain ratings have been added to the baseline and post-treatment visits as 
well as Booster sessions. 
-​
An Aura Information Handout has been added to the screening visit to improve fidelity of 
daily diary completion.  
-​
Minor grammar and rewording edits.  
-​
Added note on daily diary completion under adherence. 
 
Version Number: 1.8 
Version Date: March 23, 2020 
Summary of Revisions Made (submitted to NCCIH for review prior to COVID-19):  
-​
Updated study staff personnel.  
-​
Updated information regarding the qualifications of anesthesia residents and nurses 
placing A-lines due to IRB approval. 
-​
The A-line blood collection amount has increased slightly due to a correction of a 
previous calculation error.  
-​
The cold water bath device has been updated to a newer model.  
-​
Minor grammar and rewording edits.  
 
Version Number: 1.9 
Version Date: May 11th, 2020 
Summary of Revisions Made (submitted to NCCIH for review during COVID-19): 
-​
Updated study staff personnel.  
-​
Updated the intervention to include an option for virtual group MBSR and Nature 
education sessions, which may be more in demand due to COVID-19.  
-​
Added safety risks for video conferencing. 
 
Version Number: 2.0 
Version Date: July 13th, 2020 
Summary of Revisions Made (after EAB review): 
-​
Updated footnote to the ‘Schedule of Evaluations’ table 
-​
Added remote screening visits due to COVID-19 
-​
Clarified intervention details  
 
Version Number: 2.1 
Version Date: August 14th, 2020 
Summary of Revisions Made: 
Study Product Guidelines and Considerations​
6 of 68​Version 3.1 
​
​November 25th, 2024 

-​
The use of RAVANS has been added to the already scheduled daily home practice for 
subjects randomized to both MBSR or education control interventions.  
Version Number: 2.2 
Version Date: November 11th, 2020 
-​
Updated study staff. 
-​
Added behavioral task during PET-MRI visit.  
-​
The already approved Recent Medical History survey will be given to participants at all 
baseline and posts visits. 
-​
The exclusion criteria for weight has been clarified to also exclude participants with a 
BMI higher than 34 due to restrictions with the MRI machines.  
-​
Added COVID-19 antibody serology testing. 
-​
The A-line monitoring time has been changed to reduce the time participants will need to 
be at the center due to COVID-19. 
Version Number: 2.3 
Version Date: August 30th, 2021 
-​
Updated booster visits to allow for more flexibility as to in-person vs. virtual visits. 
-​
Updated study staff.  
-​
Updated recruitment methods per MGH IRB guidelines. 
Version Number: 2.4 and 2.5 
Version Date:  February 28th, 2022 
-​
Updated headache day eligibility criteria following discussion at External Advisory 
Board meeting 
-​
Updated screening visit procedures per recommendation by Westat 
-​
Updated study staff 
-​
Added more recruitment methods 
Version Number: 2.6 
Version Date:  April 27th, 2022 
-​
Added new policy for EMR review for SAEs per Westat guidelines  
-​
Clarified 1 month of diary completion  
-​
Clarified remote procedures due to COVID-19 
-​
Added BDI-II to screening visit in addition to PET visits 
-​
Updated study staff 
 
Version Number: 2.7 
Version Date: May 24th, 2023 
-​
Updated Study staff  
-​
Increased healthy subject enrollment total to 50  
-​
Clarified exclusion criteria 
Study Product Guidelines and Considerations​
7 of 68​Version 3.1 
​
​November 25th, 2024 

-​
Corrected maximum headache days each month to 20 throughout the document 
-​
Updated healthy subject daily diary requirement 
-​
Clarified remote consent visit information  
-​
Added information about text message communication  
-​
Added Aura Questionnaire at Screening Visit 
-​
Clarified information regarding blood draw requirements at PET-MR visit 
-​
Added information about withholding from Triptan related medications prior to the 
PET-MR visit 
 
 
Version Number: 2.8 
Version Date: July 3rd, 2023 
Updated participant attrition rate, completion, and randomization totals for migraine participants 
 
Version Number: 2.9 
Version Date: November 3rd, 2023 
-​
Updated exclusion criteria 
-​
Updated study staff roster  
 
 
 
Version Number: 3.0 
Version Date: December 26th, 2023 
-​
Updated the table reflecting the correct questionnaires given at the 3 month and 6-month 
follow-up 
-​
Eliminate COVID-19 antibody testing 
-​
Include urine pregnancy testing 
-​
Updated study staff roster 
 
Version Number: 3.1 
Version Date: November 25th, 2024 
-​
Update Study Staff Roster 
-​
Included data sharing language for Dr. Brusaferri and Tohyama that was required by the 
MGB IRB  
 
 
Study Product Guidelines and Considerations​
8 of 68​Version 3.1 
​
​November 25th, 2024 

TABLE OF CONTENTS 
Page 
Clinical Intervention Study Protocol........................................................................................... 1 
FULL PROTOCOL TITLE..........................................................................................................2 
Tool Revision History​
3 
TABLE OF CONTENTS.............................................................................................................. 6 
STUDY TEAM ROSTER​
9 
PARTICIPATING STUDY SITES​
13 
PRÉCIS​
13 
1. STUDY OBJECTIVES........................................................................................................... 14 
1.1​
Primary Objectives​
14 
1.2​
Secondary Objectives​
15 
2. BACKGROUND AND RATIONALE................................................................................... 17 
2.1​
Background on Condition, Disease, or Other Primary Study Focus​
17 
2.2​
Study Rationale​
17 
3. STUDY DESIGN..................................................................................................................... 20 
4. SELECTION AND ENROLLMENT OF PARTICIPANTS................................................21 
4.1​
Inclusion Criteria​
21 
4.2​
Exclusion Criteria​
22 
4.3​
Study Enrollment Procedures​
24 
5. STUDY INTERVENTIONS................................................................................................... 25 
5.1​
Interventions, Administration, and Duration​
25 
5.2​
Handling of Study Interventions​
27 
5.3​
Concomitant Interventions​
28 
5.3.1​
Allowed Interventions........................................................................................... 28 
5.3.2​
Required Interventions.......................................................................................... 29 
5.3.3​
Prohibited Interventions........................................................................................ 29 
5.4​
Adherence Assessment​
29 
6. STUDY PROCEDURES......................................................................................................... 29 
Study Product Guidelines and Considerations​
9 of 68​Version 3.1 
​
​November 25th, 2024 

6.1​
Schedule of Evaluations​
29 
6.2​
Description of Evaluations​
31 
6.2.1​
Screening Evaluation.............................................................................................31 
6.2.2​
Enrollment, Baseline, and/or Randomization........................................................33 
6.2.3​
Blinding................................................................................................................. 39 
6.2.4​
Treatment Visits.....................................................................................................39 
6.2.5​
Post-intervention Evaluation................................................................................. 40 
6.2.6​
3- and 6-month Follow-up (home-based Patient Reported Outcomes):................40 
7. SAFETY ASSESSMENTS......................................................................................................41 
7.1​
Specification of Safety Parameters​
41 
7.2​
Methods and Timing for Assessing, Recording, and Analyzing Safety Parameters​
44 
7.3​
Adverse Events and Serious Adverse Events​
44 
7.4​
Reporting Procedures​
44 
7.5​
Follow-up for Adverse Events​
45 
7.6​
Safety Monitoring​
45 
8. INTERVENTION DISCONTINUATION.............................................................................45 
9. STATISTICAL CONSIDERATIONS....................................................................................46 
9.1​
General Design Issues​
46 
9.2​
Sample Size and Randomization​
46 
9.2.1 Treatment Assignment Procedures...............................................................................47 
9.3 ​
Definition of Populations​
47 
9.4​
Interim Analyses and Stopping Rules​
48 
9.5​
Outcomes​
48 
9.5.1​
Primary Outcomes................................................................................................. 48 
9.5.2​
Secondary Outcomes............................................................................................. 49 
9.6​
Data Analyses​
50 
10. DATA COLLECTION AND QUALITY ASSURANCE....................................................51 
10.1​
Data Collection Forms​
51 
10.2​
Data Management​
51 
10.3​
Quality Assurance​
51 
10.3.1​
Training..................................................................................................................51 
10.3.2​
Quality Control Committee................................................................................... 52 
10.3.3​
Metrics...................................................................................................................52 
10.3.4​
Protocol Deviations............................................................................................... 52 
Study Product Guidelines and Considerations​
10 of 68​Version 3.1 
​
​November 25th, 2024 

10.3.5​
Monitoring.............................................................................................................52 
11. PARTICIPANT RIGHTS AND CONFIDENTIALITY.....................................................52 
11.1​
Institutional Review Board (IRB) Review​
52 
11.2​
Informed Consent Forms​
52 
11.3​
Participant Confidentiality​
52 
11.4​
Study Discontinuation​
53 
11.5​
Virtual Group Visits​
53 
12. COMMITTEES..................................................................................................................... 53 
13. PUBLICATION OF RESEARCH FINDINGS...................................................................53 
14. REFERENCES...................................................................................................................... 53 
Study Product Guidelines and Considerations​
11 of 68​Version 3.1 
​
​November 25th, 2024 

STUDY TEAM ROSTER  
Name: 
Location: 
Phone: 
Email: 
Eowyn Ahlstrom  
 
 
eowyn@middlepath-healingarts.com 
Alessandra Anzolin 
 
 
aanzolin@mgh.harvard.edu 
Grae Arabasz 
149 13th Street, Rm 
1304A  
Charlestown MA 02129 
617-643-0573 
garabasz@mgh.harvard.edu 
Riccardo Barbieri 
149 13th Street , Rm 2294  
Charlestown MA 02129  
617-724-1061 
barbieri@neurostat.mit.edu 
Julia Bialobrezewski 
149 13th Street, 
Charlestown MA 02129 
 
jbialobrzewski@mgh.harvard.edu 
Natalia Cepeda 
1035 Cambridge St., 
Cambridge, MA 02141 
 
ncepeda@challiance.org 
 
Suk-Tak (Phoebe) 
Chan 
149 13th Street, Rm 2301  
Charlestown MA 02129 
617-724-7194 
phoebe@nmr.mgh.harvard.edu 
Courtney Chane 
149 13th Street, Suite 
2230, Charlestown, MA 
02129 
617-726-7983 
cchane@mgh.harvard.edu 
Hsinlin T. Cheng 
15 Parkman Street 
Boston, MA 02124 
617-643-8277 
htcheng@mgh.harvard.edu  
Alexandra Comeau 
1035 Cambridge St., 
Cambridge, MA 02141 
 
acomeau@challiance.org 
 
Jody Daniels 
1035 Cambridge St., 
Cambridge, MA 02141 
 
 jdani1010@gmail.com 
Michael Datko 
2150E, 300 1st Ave 
Charlestown, MA 
619-851-7381 
mdatko@mgh.harvard.edu  
Kelli Devitte-McKee  
 
kdevitte-mckee@partners.org 
Robert R Edwards 
 
850 Boylston St,  
Chestnut Hill, MA 02467 
 
617-732-9486 
 
rredwards@bwh.harvard.edu 
 
Study Product Guidelines and Considerations​
12 of 68​Version 3.1 
​
​November 25th, 2024 

Ronald G. Garcia 
 
149 13th Street, Rm 4003 
Charlestown, MA 02129 
 
617-643-4265 
 
rgarciagomez@mgh.harvard.edu 
 
Richa Gawande 
 
1035 Cambridge St., Suite 
21A 
Cambridge, MA 02141 
 
617-591-6132 
 
rgawande@challiance.org  
 
Melaina Gilbert 
2150E, 300 1st Ave 
Charlestown, MA 02129 
 
mdgilbert@mgb.org 
Hannah Goodman 
350 Main St. Malden MA 
02148 
781-873-9814 
hgoodman@challiance.org 
Nouchine Hadjikhani 
 
75, Rm1418 
Charlestown, MA 02129 
 
617-724-5625 
 
nouchine.hadjikhani@mgh.harvard.edu 
 
Catherine Haines 
 
 
chaines@challiance.org 
Megan Heffernan  
55 Fruit St, WAC 716, 
Boston, MA 02114 
617-726-6896 
mrheffernan@mgh.harvard.edu 
 
Randy Hirschtick 
 
120, Suite 101 
Charlestown, MA 02129 
 
617-724-9602 
 
rgollub@partners.org 
 
Timothy Houle 
 
WHT-5-524, 55 Fruit 
Street 
Boston, MA 02124  
 
617-724-2111 
 
Thoule1@mgh.harvard.edu  
 
Shirley Hsu 
 
149 13th Street, Rm 
1304A  
Charlestown MA 02129 
 
617-726-8163 
 
shirley.hsu@mgh.harvard.edu 
 
Abbie Izzo  
 
 
aeizzo@mgb.org 
Ted Kaptchuk 
 
 
ted_kaptchuk@hms.harvard.edu 
 
Jordan Keels 
 
 
jkeels@mgb.org 
Minhae Kim  
149 13th Street, Suite 
2316, 
Charlestown MA 02129  
617-643-0569 
ekim35@mgh.harvard.edu 
 
Study Product Guidelines and Considerations​
13 of 68​Version 3.1 
​
​November 25th, 2024 

Kenneth Kwong 
 
 
kkwong@mgh.harvard.edu 
 
Vivian Li 
 
 
vli4@mgh.harvard.edu 
 
Marco Loggia 
 
149 13th Street, Rm 2301 
Charlestown, MA 02129 
 
617-643-7267 
 
marco.loggia@mgh.harvard.edu 
 
Frances Marin 
 
1035 Cambridge St., Suite 
21A 
Cambridge, MA 02141 
 
617-643-8770 
 
fmarin@challiance.org 
 
Alison McManus 
 
617-643-4848 
ajmcmanus@mgh.harvard.edu 
Jennifer Murphy  
149 13th Street Suite 2230 
Charlestown MA 02129 
617-724-0382 
jmurphy@mgh.harvard.edu 
Vitaly Napadow 
 
2150D, 300 1st Ave 
Charlestown, MA  
617-724-3402 
 
vitaly@mgh.harvard.edu 
 
Shahin Nasr 
 
 
shahin.nasr@mgh.harvard.edu 
 
Jonathan Polimeni 
 
149 13th Street, Rm 2301 
Charlestown, MA 02129 
 
617-724-4546 
 
jonp@nmr.mgh.harvard.edu  
 
Julie Price 
 
149 13th Street, Rm 2301 
Charlestown, MA 02129 
 
617-726-7700 
 
jcprice@nmr.mgh.harvard.edu  
 
Eva Ratai 
 
149 13th Street, Rm 2301  
Charlestown MA 02129 
 
617-726-1744 
 
eraitai@mgh.harvard.edu 
 
Bruce Rosen 
 
149 13th Street, Rm 2301  
Charlestown MA 02129 
 
617-726-5122 
 
bruce@nmr.mgh.harvard.edu 
 
Zev 
Schuman-Olivier 
 
1035 Cambridge St., 
Cambridge, MA 02141 
 
617-591-6056 
 
zschuman@cha.harvard.edu 
 
Jack Schnieders 
149 13th Street Suite 2230 
Charlestown MA 02129 
617-726-8725 
jschnieders@mgh.harvard.edu 
 
Bhavika Shah  
 
 
bshah7@partners.org 
 
Study Product Guidelines and Considerations​
14 of 68​Version 3.1 
​
​November 25th, 2024 

Shiqian Shen  
 
 
sshen2@mgh.harvard.edu 
 
Natalie Swanson 
 
 
Nswanson2@mgh.harvard.edu 
Sarasa Tohyama 
 
149 13th Street, Rm 2301 
Charlestown, MA 02129 
 
 
stohyama@mgh.harvard.edu 
 
Dana Turner 
 
55 Fruit Street 
Boston, MA 02114  
 
617-724-1063 
 
dpturner@mgh.harvard.edu  
 
Janya Utkarsh 
 
 
jutkarsh@mgb.org 
Margaret Wargo 
 
 
mwargo@mgh.harvard.edu 
Akila Weerasekera 
 
149 13th Street, Rm 2301  
Charlestown MA 02129 
 
 
aweerasekera@mgh.harvard.edu 
 
Rebecca Wells 
 
 
rewells@wakehealth.edu 
Nyera Youssef 
 
 
nyoussef@mgb.org 
 
 
 
PARTICIPATING STUDY SITES 
The Martinos Center for Biomedical Imaging, Massachusetts General Hospital 
149 13th Street, Charlestown MA 02129 
Cambridge Health Alliance – Center for Mindfulness and Compassion 
1035 Cambridge Street, Suite 21A Cambridge, MA 02141 
 
PRINCIPAL INVESTIGATOR:  
 
Vitaly Napadow, PhD, Lac 
300 First Ave, Rm2150D 
Charlestown, MA 02129  
617-724-3402 
vitaly@mgh.harvard.edu 
 
Study Product Guidelines and Considerations​
15 of 68​Version 3.1 
​
​November 25th, 2024 

PRÉCIS  
Study Title  
Boosting mind-body mechanisms and outcomes for chronic pain  
Objectives  
Primary objective: To evaluate the effects of combined Mindfulness Meditation 
(MM) + Respiratory-gated Auricular Vagal Afferent Nerve Stimulation (RAVANS 
tVNS) on brainstem and cortical response to trigeminal sensory afference, peripheral 
parasympathetic activity and neuroinflammation levels in migraine patients  
Secondary objective: To evaluate differences in brainstem and cortical response to 
trigeminal sensory afference, peripheral parasympathetic activity and 
neuroinflammation levels between migraineurs and healthy controls. 
Design and Outcomes   
Our proposal will employ a multi-modal approach to evaluate synergistic effects on 
migraine pathophysiology following MM and RAVANS tVNS. We will apply 
ultrahigh field (7T) fMRI, H-MRS, PET/MRI neuroimaging and autonomic testing at 
baseline and following 8-weeks of therapy in a 2x2 randomized longitudinal trial 
design with groups receiving RAVANS or sham tVNS, and MM training or education 
control.  
Interventions and Duration  
MM training will utilize Mindfulness-Based Stress Reduction (MBSR), which 
focuses on purposely cultivating an attitude of non-judgmental awareness towards 
present-moment experiences, through formal and informal mindfulness meditation 
practices. MBSR will be provided following commonly accepted standards of 
practice and will be adapted into weekly sessions (attended virtually, i.e. online) that 
last up to 2 hours. In addition, each week, there will also be weekly 30-minute booster 
visits with a focused attention, mindfulness of breathing recording while receiving 
RAVANS or sham.  The education control will be didactic and include viewing of 
nature videos that are matched in duration to the amount of meditation dose provided 
during each MBSR group. 
 
Study Product Guidelines and Considerations​
16 of 68​Version 3.1 
​
​November 25th, 2024 

Figure 1. Study Schema for 2x2 longitudinal neuroimaging study evaluating 
RAVANS tVNS (RAVANS) and Mindfulness Meditation (MM)  
Sample Size and Population 
Episodic migraine subjects (N=96) who fulfill the International Classification of 
Headache Disorders – Third-beta edition criteria for the diagnosis of migraine will be 
enrolled and randomized to one of the 4 N=24 groups. A group of 50 healthy controls 
will also be enrolled for baseline comparisons. 
1. STUDY OBJECTIVES 
1.1​
Primary Objectives 
For this Program Project Grant, there will be 3 Projects, each evaluating a single 
primary outcome:  
Project 1: 
- Evaluate the effects of combined MM + RAVANS tVNS on brainstem and cortical 
response to trigeminal sensory afference in migraine patients  
Hypothesis: Combined MM + RAVANS tVNS, compared to monotherapy and 
control interventions, will significantly reduce cortical amplification ratio to 
trigeminal afference (posterior insula to spinal trigeminal nuclei percent signal 
change) in migraine patients. 
 
Project 2: 
- Evaluate the effects of combined MM + RAVANS tVNS on peripheral 
parasympathetic activity of migraine patients  
Hypothesis: Combined MM + RAVANS tVNS, compared to monotherapy and 
Study Product Guidelines and Considerations​
17 of 68​Version 3.1 
​
​November 25th, 2024 

control interventions, will significantly increase High Frequency-Heart Rate 
Variability (HF-HRV) response to sensory/affective stressors.  
 
Project 3: 
- Evaluate the effects of combined MM + RAVANS tVNS on neuroinflammation in 
migraine patients  
Hypothesis: Combined MM + RAVANS tVNS, compared to monotherapy and 
control interventions, will significantly reduce PET [11C]PBR28 ligand binding in 
the posterior insula of migraine patients. 
 
1.2​
Secondary Objectives 
Project 1: 
- Evaluate differences in cortical amplification ratio and habituation in response to 
trigeminal sensory afference between migraine patients and healthy controls 
Hypothesis: At baseline, interictal episodic migraine patients will present 
increased cortical amplification ratio to trigeminal afference and reduced 
habituation in thalamus, hypothalamus and insula cortex compared to healthy 
controls. 
 
-Investigate the effects of combined MM + RAVANS tVNS on brain glutamate levels 
of migraine patients 
Hypothesis: Combined MM+RAVANS tVNS, compared to monotherapy and 
control interventions, will result in significant reduction of glutamate 
concentrations in thalamus and insula in migraine patients. 
 
-Evaluate if changes in brain response to trigeminal afference are associated with 
glutamate concentrations  
Hypothesis: Individuals showing the most adaptive changes in cortical 
amplification and habituation will also demonstrate the greatest reductions in 
glutamate concentrations.  
 
Project 2: 
- Evaluate differences in HF-HRV response to sensory/affective stressors between 
migraine patients and healthy controls 
Hypothesis: At baseline, interictal episodic migraine patients will present lower 
HF-HRV response to sensory/affective stressors in comparison to healthy 
controls. 
 
- Evaluate central autonomic network (CAN) response to sensory/affective stressors 
in migraine patients and its response to combined MM + RAVANS tVNS  
Hypotheses:  
Study Product Guidelines and Considerations​
18 of 68​Version 3.1 
​
​November 25th, 2024 

-At baseline, as compared to healthy controls, migraine patients will demonstrate 
larger amygdala response to sensory/affective stressors.  
- Combined MM+RAVANS tVNS, compared to monotherapy and control 
interventions, will result in a significant decrease in amygdala response to 
sensory/affective stressors in migraine patients.  
 
- Evaluate the relationship between CAN activation and peripheral parasympathetic 
response to sensory/affective stressors in migraine patients and its response to 
combined MM + RAVANS tVNS  
Hypotheses:  
-At baseline, as compared to healthy controls, migraine patients will show 
reduced association between activity of CAN regions (insula, MCC, mPFC) and 
HF-HRV response to sensory/affective stressors.  
- Combined MM + RAVANS tVNS, compared to monotherapy and control 
interventions, will result in a significant increase in the correlation between CAN 
activation and HF-HRV response to sensory/affective stressors in migraine 
patients.  
 
Project 3: 
- Evaluate differences in neuroinflammation levels between migraine patients and 
healthy controls 
Hypothesis: At baseline, Interictal episodic migraine patients will present elevated 
PET [11C]PBR28 ligand binding in the posterior insula compared to healthy 
controls. 
 
- Evaluate the effects of combined MM + RAVANS tVNS on 
neuroinflammation-linked low frequency fluctuations in brain fMRI signals (fALFF)  
Hypotheses:  
- Combined MM+RAVANS tVNS, compared to monotherapy and control 
interventions, will result in a significant fALFF signal reduction in migraine 
patients.  
 
2. BACKGROUND AND RATIONALE 
2.1​
Background on Condition, Disease, or Other Primary Study Focus 
Migraine is a highly prevalent disease (36 million Americans)1. A recent study 
examining disability-adjusted life years (DALYs)2 has concluded that migraine is the 
3rd most prevalent medical disorder on the planet, and that migraine accounts for 30% 
of the global burden and more than 50% of the disability burden attributable to all 
neurological diseases worldwide. Overall, migraine is the 4th ranking cause among 
women and the 7th ranking case of all disease-associated disability worldwide. In the 
US, migraine costs employers about $14.5 billion a year because of missed workdays 
Study Product Guidelines and Considerations​
19 of 68​Version 3.1 
​
​November 25th, 2024 

and impaired work function3. Migraine is a condition with multifactorial 
neurobiological underpinnings that are steadily being characterized. Migraine is a 
neurovascular disorder characterized by central sensitization4,5, specifically in the 
brainstem trigeminal sensory complex6-9, leading to up-regulation of cortical 
excitability10,11. Behaviorally, central sensitization can manifest as hyperalgesia, 
allodynia, and impaired habituation, which have been commonly reported in migraine 
patients, even during the interictal phase (between attacks)12,13. This excitability is 
also associated with dysregulation of the autonomic nervous system14,15 and both may 
stem from and up-regulate neurogenic neuroinflammation mediated by microglia 
and/or astrocyte activation16. 
Migraine management is a challenging issue, no single therapy has proven to be 
completely successful for alleviating migraine, and while many mind-body therapies 
have shown promise for chronic pain disorders, including migraine headache, the 
efficacy of any single-modality treatment is typically modest. Finding a way to boost 
clinical outcomes for these safe and well-accepted therapeutic modalities is a 
crucially important goal. It is well documented17-19, and recommended in the recent 
Institute of Medicine (IOM) report on pain20, that a multimodal approach is optimal 
for chronic pain management. The concept behind a multimodal approach for chronic 
pain is to target several convergent pathways, thereby enhancing the benefits of each 
individual approach17-19.  Mind-body therapies can involve either or both “mind” and 
“body” elements. To date, however, better integration of “top-down” and 
“body-based” therapies has been hampered by a lack of mechanistic understanding of 
how these interventions might interact, presenting a knowledge gap that, when filled, 
could help optimize care by determining approaches most likely to have a synergistic 
salubrious effect. 
 
2.2​
Study Rationale 
Mindfulness meditation (MM) is a top-down intervention that encourages 
non-judgmental awareness and acceptance towards inner experiences (thoughts, 
emotions) and physical sensations. MM encompasses various techniques, including 
focused awareness of sensory, emotional, and cognitive events, and open 
monitoring21,22. As pain experience involves unpleasant sensory and emotional 
experiences, and is strongly influenced by negatively-valenced evaluative 
processes23,24, MM has significant potential to shape the chronic pain experience. In 
fact, the first MM research trial targeted chronic pain, and was published by Jon 
Kabat-Zinn in 198225. Recent large N clinical trials have shown promise for reducing 
pain26-30. MM training has also been successfully applied for migraine headache, by 
our group and others31-33. However, the neural mechanisms supporting MM-mediated 
pain relief are poorly understood34, and may differ from those supporting placebo 
analgesia35,36.  
MM likely operates by top-down mechanisms; indeed, multiple fMRI studies 
suggest that applying mindfulness techniques during painful stimulation enhances 
activation of cortical pain-inhibitory circuits involving ACC/mPFC, and reduces 
pain-related activity in the insula and thalamus36,37. Additionally, attention to breath 
has been demonstrated to increase activity in prefrontal cortical regions38, including 
Study Product Guidelines and Considerations​
20 of 68​Version 3.1 
​
​November 25th, 2024 

mPFC39, and MM training strengthened mPFC connectivity with posterior insula 
during an attention to breath task40.  Importantly, mPFC is key in linking context (e.g. 
allostatic stressors) with adaptive emotional responses and is characterized by a dense 
array of subcortical connections41. Hence, mPFC is a key region for top-down 
modulation of subcortical and cortico-limbic hyperexcitability. A recent MR 
spectroscopy (H-MRS) study also suggested that experienced meditators show 
reduced glutamate levels in the thalamus42. As animal models of chronic pain show 
reduced glutamate in mPFC43 and diminished inhibitory control of subcortical regions 
such as amygdala and thalamus. Moreover, recent reviews on MM and pain highlight 
the ability of meditation-based approaches to reduce sensitivity to pain21,34,44. 
Behaviorally, indicators of central sensitization are often measured using Quantitative 
Sensory Testing (QST), which applies calibrated noxious thermal and/or mechanical 
stimuli to evaluate the effects of an intervention or manipulation on pain responses. 
To date, more than a dozen QST studies have revealed that long-term MM 
practitioners (many with thousands of hours of training) exhibit reduced pain 
sensitivity compared to non-practitioners45-48, and that even brief training in MM 
principles and breathing practices lowers pain sensitivity in  subjects35-37,49-56. While 
much of this research has been conducted in healthy volunteers, MM has also been 
shown to reduce indices of central sensitization (e.g., post-MM, patients report less 
pain in response to administration of noxious stimuli) in chronic low back pain57 and 
fibromyalgia patients58. The time frame for MM effects has not been definitively 
elucidated; brief sessions (e.g., 15-20 minutes) of breath-focused mindfulness training 
reduce sensitivity to pain in healthy subjects52, suggesting rapid benefits. However, 
practice appears to facilitate MM’s capacity to reverse sensitization processes34,59, as 
individuals with more MM experience are most able to reduce intensity and 
unpleasantness of noxious stimuli48,60, and most effectively modulate insula46 activity. 
Collectively, MM may reduce CNS sensitization by recruiting mPFC pain-inhibitory 
pathways and reducing activation in pain-processing areas that frequently exhibit 
enhanced excitability in persistent pain34,59,61. 
The current study proposes to enhance the relaxing and self-regulatory effects of 
MM by incorporating a targeted bottom-up neuromodulatory intervention, 
transcutaneous vagus nerve stimulation (tVNS). While pharmacological options for 
migraines have targeted brainstem neuromodulatory centers, including serotonergic 
(raphe nuclei) and noradrenergic (locus coeruleus) nuclei62,63, novel neuromodulation 
stimulation therapies as tVNS have also been proposed64,65. The vagus nerve is 
regarded as the main parasympathetic conduit of the autonomic nervous system 
(ANS)41, and consists of both afferent and efferent fibers. Most vagal fibers (~80%) 
are afferents and carry sensory information from the head, neck, abdomen, and thorax 
to (mainly) the nucleus tractus solitarii (NTS)42–44. NTS information is then 
communicated to neuromodulatory brainstem nuclei for diffuse monoamine systems 
– i.e. locus coeruleus (LC) and raphe nuclei66,67. VNS has demonstrated efficacy in 
migraine prevention and reduction of headache severity68-70, and while the precise 
analgesic mechanisms of VNS are unknown, vagal afference relayed to NTS in the 
medulla may modulate cortical/subcortical excitability and connectivity with higher 
brain structures69 via these monoaminergic neuromodulatory systems. For instance, 
LC could be involved in vascular regulation of migraine through direct projections to 
Study Product Guidelines and Considerations​
21 of 68​Version 3.1 
​
​November 25th, 2024 

both intra- and extra-cranial vasculature71, while both serotonergic and noradrenergic 
systems are known to suppress cortical/subcortical hyper-excitability and cortical 
spreading depression63, a slowly propagating wave of sustained strong neuronal and 
glial depolarization that underlies migraine aura and activates downstream 
inflammatory and nociceptive pathways72. Indeed, a previous animal study73 has 
shown that VNS significantly suppresses cortical spreading depression susceptibility 
in rat occipital cortex. Despite the therapeutic potential of VNS, adverse events 
associated with surgery and chronic stimulation limit broad applicability74. 
Importantly, the NTS also receives somatosensory afference via the purely afferent 
auricular branch of the vagus nerve (ABVN)75,76, which innervates the auricle (outer 
ear), most consistently at the cymba conchae. Non-invasive (transcutaneous) methods 
of ABVN stimulation (tVNS) have been proposed77, and preliminary neuroimaging 
studies have found that tVNS modulates brainstem and cortical areas similar to 
classical VNS78-80. Commercial tVNS devices have been approved for treatment of 
migraine in Europe, and one company is currently seeking FDA approval (but is not 
yet available) in the US, following publication of a clinical trial suggesting that tVNS 
reduces migraine frequency81. Interestingly, it is well known that the dorsal medullary 
vagal system (which includes NTS) operates in tune with respiration (e.g. respiratory 
sinus arrhythmia). Second-order NTS relay neurons receive afference from 
pulmonary stretch receptors and aortic baroreceptors. NTS also receives inhibitory 
inputs from medullary ventral respiratory group (VRG) nuclei during inspiration, and 
facilitation during expiration82-84. For these reasons, our group has proposed that 
ABVN stimulation gated to expiration may optimize brainstem targeting85, and 
developed the Respiratory-gated Auricular Vagal Afferent Nerve Stimulation 
(RAVANS) technique. In addition to enhanced targeting due to VRG influence on 
NTS, by supplying afference with intermittent, naturally irregular stimulation, 
RAVANS tVNS may also limit the neural habituation occurring with constant 
high-frequency stimulation, common with most VNS and tVNS applications86.   
Combining MM with RAVANS tVNS is promising on both a conceptual and 
neurophysiological level. We propose that respiratory-coupled pathways for MM 
mechanisms will be potentiated by RAVANS’ respiratory-gated, bottom-up 
neuromodulation converging on overlapping brain circuitry. This will then manifest in 
synergistic improvement for migraine pathophysiology, and ultimately, clinical 
outcomes.  
 
3. STUDY DESIGN 
We will employ a multi-modal approach to evaluate the effects on migraine 
pathophysiology following MM and RAVANS tVNS in a 2x2 randomized longitudinal 
trial design. Patients that complete the 4-week diary lead-in prior to the baseline sessions 
will be randomized into one of 4 possible treatment groups: 8 weeks of (1) active tVNS 
and mindfulness meditation (MM), (2) inactive tVNS and MM, (3) active tVNS and 
education control (EduCtl), or (4) inactive tVNS and EduCtl. Twenty fourpatients will be 
randomized in each treatment group, for a total of 96 patients available for analysis 
(Figure 1). Subjects will be asked to come to the Martinos Center and Cambridge Health 
Alliance (CHA) Center for Mindfulness and Compassion for a total of 23 visits: 4 visits 
Study Product Guidelines and Considerations​
22 of 68​Version 3.1 
​
​November 25th, 2024 

prior to treatment (1 screening visit, 1 behavioral/Autonomic Nervous System Testing 
(ANS) session, 1 fMRI and 1 PET/MRI sessions, all at the Martinos Center), 16 
treatment visits at CHA or remote using Zoom over 8 weeks,  3 imaging/ANS visits post 
treatment, and 2 online follow-ups. Patients not willing to perform PET as part of the 
PET/MR visits will not check the related PET box on the consent form. They will be able 
to perform other study procedures and stay in the study. Additionally, 50 healthy 
volunteers will be enrolled to complete baseline procedures only (Visits 1-4).  
 
 
 
        Figure 1. Study design for 2x2 longitudinal neuroimaging study evaluating RAVANS 
tVNS (RAVANS) and Mindfulness Meditation (MM) 
 
Primary outcomes will include the changes post-therapy compared to baseline in the 
cortical amplification ratio to trigeminal afference as assessed by fMRI, the HF-HRV 
response to sensory/affective stressors measured in the ANS sessions and the [11C]PBR28 
PET ligand binding in posterior insula, as quantified in the PET/MR sessions. 
We will conduct at least 2 MM and 2 education control groups per year, with 
staggered start dates over the years to achieve relative balance among seasons. We will 
ensure that MM group leaders are balanced across tVNS and sham groups to reduce the 
impact of leader variability. We will aim for 8 participants per group (minimum:6, 
maximum: 10) with a goal of 6-10 MM and 6-10 education control patients running 
concurrently on different days of the week (we are prepared for more if enrollment 
schedule dictates).  
Given the logistics of recruiting and enrolling subjects in a group-intervention for 
which groups of 6-10 need to be formed and subjects will likely drop out if required to 
wait several months for a new group to form, we will recruit in a temporal sequence with 
fully randomized order of treatment. We will not able to stratify patients, however, to 
reduce the chances of sampling bias, defined narrowly as systematic differences across 
Study Product Guidelines and Considerations​
23 of 68​Version 3.1 
​
​November 25th, 2024 

randomized groups, we will employ a modified version of covariate adaptive 
randomization. In covariate adaptive randomization, a new participant is sequentially 
assigned to a particular treatment group by considering specific covariates and previous 
assignments of participants. However, in this study, individuals must be enrolled in the 
nearest temporal cohort in relation to their screening. To accommodate this fact, each 
pool of currently eligible individuals will each be scored based on their potential to 
balance the experimental groups, conditional on previous assignments and their 
characteristics. Assignments will be based on a solution that places the maximum number 
of individuals currently under consideration into the current cohort while assigning the 
fewest possible to the next cohort (i.e., a two-variable optimization). This is important as 
any delay from when subjects express desire to enroll in the study and actually receiving 
therapy (at absolute minimum, the time would already be 1 month of daily diaries plus 3 
weeks of fMRI and PET-MR scans and behavioral sessions), impacts dropout. Thus, at 
worst subjects would join the next group cohort and the method of minimization will be 
used to reduce the difference in groups if the current participant was assigned to the 
current group or the next available group. The variable considered for balance will be 
monthly headache frequency. This variable will be assessed during the daily diary run-in 
period.  
All patients and study staff will be blinded, except for the study coordinator, who will 
execute the randomization scheme, and Cambridge Health Alliance (CHA) study staff 
directly involved in the delivery of this behavioral intervention (i.e. MM trainers). 
Recruitment and outcome assessment will be performed by blinded personnel. 
 
4. SELECTION AND ENROLLMENT OF PARTICIPANTS  
4.1​
Inclusion Criteria 
Participants must meet all of the following inclusion criteria to participate in this 
study: 
1.​ Subjects must be between 18 and 65 years of age. 
2.​ The diagnosis must come from a neurologist or other qualified MD and meet 
International Classification of Headache Diagnosis, Version 3 (ICHD-3) beta 
criteria for migraine according to either of the categories: 
ICHD-3 beta 1.1: Migraine without aura 
ICHD-3 beta 1.2: Migraine with aura 
3.​ The frequency of migraine attacks must be at least 4 migraine-days per month. 
4.​ The duration of the disease must be of at least one year. 
5.​ Willingness to attend twice-weekly treatment sessions, complete daily diaries 
throughout study, and engage in 40-60 minutes of home practice or equivalent (if 
randomized to EduCtl) per day during treatment.  
6.   Able to give written consent and participate in group interventions in English. 
​
 
Inclusion criteria for healthy volunteers: 
 
1.​ Subjects must be between 18 and 65 years of age. 
Study Product Guidelines and Considerations​
24 of 68​Version 3.1 
​
​November 25th, 2024 

2.​ Ability to give written consent. 
 
4.2​
Exclusion Criteria 
All candidates meeting any of the following exclusion criteria at baseline will be 
excluded from study participation: 
1.​ Greater than 20 headache days per month  
2.​ Major systemic illness (e.g., brain tumor, severe hypertension) or unstable 
medical/psychiatric condition (e.g., suicide risk, requiring immediate treatment or 
that could compromise protocol adherence. 
3.​ Evidence of relevant co-morbidity, systemic or not, with potential to substantially 
interfere with the phenotype of the conditions studied in the present protocol. 
4.​ A history of neurological disease or injury, including a history of seizures or 
significant head trauma (i.e., extended loss of consciousness, neurological 
sequelae, or known structural brain lesion), which may confound the results of the 
study as determined by the Clinical Core. 
5.​ Symptoms that could impact protocol adherence or be disruptive to group 
participation (e.g., Tourette’s, schizophrenia with current psychosis, bipolar 1 
disorder, severe OCD, current severe episode of major depression, dissociative 
disorder, severe PTSD, severe personality disorder, traumatic brain injury, severe 
agoraphobia, etc.) as determined by the Clinical Core. 
6.​ Medication overuse, using ICHD-3 beta criteria framework for medication 
overuse headaches, as determined by Clinical Core. 
7.​ Other chronic pain disorder whose intensity exceeds the intensity of pain during 
migraine headaches. 
8.​ Moderate or high levels of opioid use (>60mg Morphine equivalents).    
9.   Participation in other concurrent therapeutic trials. 
10. Current training or training in the past 2 years in mindfulness (MBCT, MBSR) or 
in the Relaxation Response. 
11. Relevant mindfulness meditation practice for an average of 10+ minutes a day in 
the past 3 months.  
12. Conditions of skin or anatomy that affect left auricle or forehead skin and could 
impact placement of electrodes for tVNS or forehead stimulation. 
13. Severe Raynaud syndrome or peripheral neuropathy will prompt Clinical Core 
review to determine eligibility. 
14. New pharmacotherapy started within 4 weeks of the screening visit that could 
impact study as determined by the Clinical Core. 
15. Subjects who are prescribed preventative calcitonin gene-related peptide (CGRP) 
medications that include CGRP antibodies and oral CGRP receptor antagonists 
and have been taking them for <3 months before screening. 
16.​Unwilling to maintain consistent pharmacotherapy for the duration of the study 
that could impact study as determined by the Clinical Core. 
17.​Meets criteria for active, non-remitted, DSM-V Moderate or Severe Substance 
Use Disorder, or demonstrates regular substance use (assessed by self-report 
and/or saliva screening) in a manner which would impact protocol or be 
disruptive to group as determined by Clinical Core. 
Study Product Guidelines and Considerations​
25 of 68​Version 3.1 
​
​November 25th, 2024 

18.​General fMRI safety exclusion criteria listed below. 
19.​Any impairment, activity or situation that in the judgment of the Study 
Coordinator or Principal Investigator would prevent satisfactory completion of the 
study protocol. This includes unreliable or inconsistent completion of daily 
diaries, as determined by the Clinical Core. 
20. A diagnosis of a significant pulmonary disease, e.g., COPD that could impact 
participation in breathing tasks as determined by Clinical Core 
21. Diagnosis of significant cardiovascular or cerebrovascular disease [e.g. congestive 
heart failure, stroke, cardiac conduction disorders (including: 
bundle branch block, heart block, long Q-T syndrome), history of asystole or 
non-sustained ventricular tachycardia] as determined by Clinical Core.  
22. Bradycardia (defined as resting heart rate <50 bpm), or  
23. Hypotension (defined as blood pressure <90/60 mmHg) that would impact study 
participation as determined by the Clinical Core.  
24. History of COVID-19 infection within the past 3 months WITH neurological 
symptoms that required hospitalization as determined by the Clinical Core.  
 
Exclusion criteria for healthy volunteers: 
 
1.​ The same as for patients, with the addition of current or past history of migraine 
or chronic pain. 
2.​ First degree relatives with a history of migraine. 
 
Combined fMRI and PET-MR safety exclusion criteria:  
1.​ Electrical implants such as cardiac pacemakers or perfusion pumps 
2.​ Ferromagnetic implants such as aneurysm clips, surgical clips, prostheses, 
artificial hearts, valves with steel parts, metal fragments, shrapnel, metallic tattoos 
anywhere on the body, tattoos near the eye, or steel implants ferromagnetic 
objects such as jewelry or metal clips in clothing 
3.​ Pregnant, suspected to be pregnant or actively trying to become pregnant (a 
negative STAT quantitative serum hCG pregnancy test is required before the 
subject can participate for PET-MR visits) 
4.​ Breastfeeding 
5.​ Pre-existing medical conditions including a likelihood of developing seizures or 
claustrophobic reactions, and any greater than normal potential for cardiac arrest; 
6.​ Is unable to lie comfortably on a bed inside a PET-MR or fMRI scanner with their 
head in the field of view for at least 90 minutes as assessed by physical 
examination and medical history (e.g. back pain, arthritis) 
7.​ Less than 18 years of age 
8.​ > 300 lbs (weight limit of the fMRI table) or BMI >34.  
 
PET-MR safety exclusion criteria 
1.​ History of Type I or Type II diabetes mellitus; unless well managed 
2.​ Use of certain antibiotics such as minocycline 
Study Product Guidelines and Considerations​
26 of 68​Version 3.1 
​
​November 25th, 2024 

3.​ Routine use of benzodiazepines or any use in the 2 weeks prior to the scan(s), 
except clonazepam, lorazepam, and alprazolam, which show very low binding 
affinity to TSPO  
 
Exclusion Criteria for placement of arterial line (an optional choice for patient 
subjects and healthy volunteers): 
Contraindications to placement of arterial line (abnormal result on modified 
Allen’s test on both hands; Raynaud syndrome; bleeding disorder; use of 
anticoagulants such as Coumadin, Plavix or Loven 
3.3​
​
Study Enrollment Procedures  
​
We will utilize a mixed methods approach to recruitment. MGH Headache and 
Neuropathic Pain Unit, directed by Dr. Cheng, a co-investigator of the study, has 5 
neurologists and a nurse practitioner who see an average of more than 500 migraine 
headache patients per month. The BWH’s Division of Headache and Pain has 7 
attending neurologists and two Headache Medicine fellows who together see an 
average of 210 migraine headache patients per month. Potential subjects will also be 
given study flyers at their subsequent physician visits. We will also use the Partners 
clinical studies website (http://clinicaltrials.partners.org/), the Partners Rally website, 
and the Partners Research Patient Data Registry (RPDR). We will also use 
information booths and Dr. Cheng’s patient symposium for recruitment. MGH has 
adopted a new system to replace RODY which allows the use of Research 
Invitations sent through Patient Gateway or regular mail to recruit patients without 
physician permission. Under this new approach, all patients are “opted in” to receive 
Research Invitations but have the option to opt out of receiving these notices. Study 
staff will make sure that patients who opt out are filtered out of the recruitment list 
(e.g., from RPDR, Epic, etc.) and they are not sent the Research Invitation. Study 
staff will also use social media ads and patient recruitment services or registries 
(such as Trial Facts or Research Match) to reach more participants. The PI will 
conduct ongoing monitoring of patient responses to ensure that the selection criteria 
are identifying the right patients, and complaints about this method of recruitment 
will be submitted to the IRB as an “other event”. Furthermore, MGH & BWH 
hospitals have a database system for clinical research (RSVP) that can identify 
patients with migraines, who have agreed to be contacted for research studies. 
Additionally, advertisements for the study will be posted in CHA neurology and 
primary care sites.  
If necessary, as back-up, we have found that a combination of standard methods 
(e.g. provider referral, flyers, print ads) as well as relatively new methods (e.g., 
internet, targeted Facebook ads) can significantly boost recruitment, using 
IRB-approved language. To encourage retention, once subjects complete 1 month of 
daily diaries and pass inclusion criteria, they will be given a proposed study visit 
schedule and will not be allowed to proceed to neuroimaging sessions unless they 
can commit to the proposed schedule and daily home practice of 40-60 minutes for 
both arms. Once participants reach on month of daily dairies, before the baseline 
visits, unblinded members of the Clinical Core will review eligibility criteria. If the 
participant has less than 4 or more than 20 headaches in that time frame they would 
Study Product Guidelines and Considerations​
27 of 68​Version 3.1 
​
​November 25th, 2024 

be considered no longer eligible to move onto the baseline visits. Migraine 
prevalence is higher amongst women, so we expect to have an unequal recruitment 
between sex.  
To mitigate subject attrition, we will offer a study specific schedule upon 
completion of the daily diaries clearly illustrating the logistics of the subjects’ 
involvement.  We will schedule subjects for all of their visits at the beginning of the 
study and follow up with reminder phone calls and/or e-mails 24-48 hours prior to 
each visit; we have found that this method reduces the number of withdrawn subjects 
and supports protocol compliance.  We will implement several innovative 
patient-centered engagement practices that support retention, including offering 
twice monthly engagement phone calls to subjects in all arms with brief informal 
interviews about study experience, ongoing participant advisory board meetings 
twice yearly to get focus group feedback about procedures that enhance retention87,88. 
Our experience was that these methods increase retention by 40%. 
 
5. STUDY INTERVENTIONS  
5.1​
Interventions, Administration, and Duration  
RAVANS procedures 
Experimental intervention sessions will take place at the Cambridge Health 
Alliance Center for Mindfulness and Compassion (CMC), directed by Zev 
Schuman-Olivier. RAVANS tVNS will be performed with electrodes attached to the 
surface of the auricle. A small current will be delivered with a safe battery-powered, 
constant-current, portable stimulator. Current amplitude will be set from 0.1 to 10 mA 
based on subject’s perception – i.e. ‘moderately strong but not painful”. Stimuli will 
consist of a 1.5-sec train of monopolar rectangular pulses with 300 µS pulse width, 
delivered at 100 Hz, initiated 0.1 seconds following peak inspiration. Respiratory 
gating for stimulation will require real-time evaluation of the respiratory cycle. For 
subjects randomized to sham stimulation groups, the electrodes in the ear will remain 
as described above, but a “Sham” stimulation mode will be selected in the stimulation 
device, which does not provide electrical stimulation. Subjects will be told that 
stimulation will be at a fixed level and will be told that they “may or may not feel 
anything at the ear,” and asked if the stimulation is “painful or not”, to promote 
compliance with the therapy and maintain blinding using a Credibility 
Questionnaire89. These tVNS procedures will be used in conjunction with MM 
training or EduCtl, as described below.  
 
Mindfulness Based Stress Reduction Intervention (MBSR) 
MM training encourages nonjudgmental awareness and acceptance of inner 
experiences (thoughts, emotions) and physical sensations. Our mindfulness training 
intervention (MBSR) is a semi-standardized behavioral intervention that consists of 8 
weekly 2-hour classes and a 4-hour retreat with an instructor. MBSR is a highly 
studied method for training people to practice MM. MM may enhance self-regulation 
and reduce stress through cognitive and emotional processing mechanisms.  
Study Product Guidelines and Considerations​
28 of 68​Version 3.1 
​
​November 25th, 2024 

Subjects will participate in an intervention which will include virtually (i.e. 
online) attended group sessions and in-person/online booster visits. The group 
sessions will take place once per week, with a virtual connection using a secure video 
conferencing computer application (i.e., Zoom). The study has CHA IT-approved 
iPads that could be given to participants during the study to help facilitate 
participation if needed. During the virtual MBSR sessions, breakout rooms will be 
introduced with different group members as well as movement breaks at least every 
60 minutes to ensure subjects’ engagement. In order to ensure fidelity of the MBSR 
intervention, we will have 3 layers of quality assurance. The first is ensuring all 
MBSR groups will be led by experienced MBSR teachers who have received 
individual supervision from supervisors affiliated with the University of 
Massachusetts Center for Mindfulness (the originators of MBSR). Second, teachers 
will have ongoing regular weekly supervision from members of an expert MBSR 
consultative team consisting of certified MSBR teachers and experts who have led 
MBSR for patients with migraines.  Third, subjects will consent to having each 
session recorded with a digital video camcorder (both education control and MBSR). 
We will record all of the MBSR and education control sessions and have an 
independent auditor watch, listen to, and evaluate 10% of the sessions. We will use a 
validated process for measuring both fidelity and adherence in mindfulness-based 
programs and all teachers will be rated for competence using the Mindfulness-Based 
Interventions: Teaching Assessment Criteria (MBI:TAC). On a monthly basis when a 
group is being implemented, group supervisors will review selected footage (e.g., 
delivery of specific experiential components, inquiry period, etc.) from at least 1 of 
the sessions and give the group leader fast and routine feedback to prevent drift.  
Individual “mindfulness of breathing” booster sessions including RAVANS-tVNS 
administration will occur twice a week for 8 weeks. This choice of mindfulness of 
breathing was supported by a recent dismantling study that reported focused attention 
practice on breath was associated with faster improvement in affective disturbances 
compared with open monitoring practices90. In addition, use of RAVANS or Sham 
tVNS with breathing mindfulness will be included in home practice sessions and will 
represent 20-30 minutes of the 40-60 minutes of daily home practice. Note that home 
practice is to be encouraged on 4 out of 7 days per week, and is not required on days 
where the participant will participate in a MBSR session. The daily administration of 
tVNS was selected based on a previous RCT that found this intervention to be safe 
and beneficial for the reduction of headache days in patients with episodic migraine 
after three months of treatment.81  The compliance and duration of home practice will 
be recorded on StudyTRAX with morning and evening daily headache diaries or with 
a paper form filled out by the participant, and will also be tracked objectively by a 
logfile automatically generated by the device. 
 
 
Education Control Intervention 
In order to keep participants blind to their cohort assignment and to have a control 
group that includes enough content to be matched to MBSR (eight 2-hr visits) on 
attention and practice doses, we propose using an innovative education control 
training. Visits in the EduCtl condition will be matched for the amount of professional 
Study Product Guidelines and Considerations​
29 of 68​Version 3.1 
​
​November 25th, 2024 

contact and will include information about the impact of nature on physical and 
mental health. An equal number of meetings will take place on a weekly basis, and a 
one-time 4-hour retreat will also be included. Subjects will participate in an 
intervention which will include virtual group sessions and in-person/online booster 
sessions. The virtual group sessions will take place on a secure video conferencing 
computer application (i.e., Zoom).   
The education control program will include inspirational discussion and activities 
related to encouraging people to get connected to nature to reduce stress. This control 
has acceptability among migraineurs because they are aware of the tendency of 
different artificial environments to provoke migraines. The education control will be 
didactic and include viewing of nature videos that are matched in duration to the 
amount of meditation dose provided during each MBSR group. The nature videos 
will occur once per session and last approximately 30 minutes with approximately 
3-minute long sections, which will vary in content with both pleasant/neutral (e.g., 
calm lake, ocean cliffs, alpine meadows, sunsets, peaceful animals) and unpleasant 
(e.g., fox eating prey, crawling insects, snakes slithering, bees swarming) videos of 
nature. An equal ratio of pleasant, neutral, and unpleasant sections will be used in 
each video, in an attempt to mimic the experience of mindfulness meditation, which 
is not always relaxing/pleasant. Education content will not be related to etiology or 
triggers of migraine headaches or stress reduction/health behavior change to prevent 
confounding. During the virtual sessions, breakout rooms will be introduced with 
different group members as well as movement breaks at least every 60 minutes to 
ensure subjects’ engagement. The EduCtl program will not include specific 
instruction in breathing techniques, mindfulness, or cultivation of non-judgmental 
awareness. Interpersonal and group-building exercises will be conducted to parallel 
the interpersonal and social support aspect of MBSR. Readings or other nature related 
content will be assigned each week that will be equal in time commitment to the daily 
mindfulness home practice assignments. EduCtl group sessions will be led by 
experienced group leaders with at least a master’s-level degree or with an equivalent 
level of group leadership experience.  ​
 
Individual EduCtl booster sessions with RAVANS tVNS will occur twice a week 
for 8 weeks. During the tVNS sessions on booster sessions, participants will watch 30 
minutes of nature videos. In addition, similarly to the MBSR arms, the use of 
RAVANS or Sham tVNS will be included in home practice sessions for the Education 
control intervention and will represent 20-30 minutes of the 40-60 minutes of daily 
home practice. The compliance and duration of home practice will be recorded on 
StudyTRAX with morning and evening daily headache diaries or with a paper form 
filled out by the participant, and will also be tracked objectively by a logfile 
automatically generated by the device. 
 
 
5.2​
Handling of Study Interventions  
MBSR is a standardized, well-defined and systematic patient-centered educational 
meditation practice. MBSR generally includes an orientation session, but given the 
RCT structure of the study, the orientation will be modified and incorporated into the 
Study Product Guidelines and Considerations​
30 of 68​Version 3.1 
​
​November 25th, 2024 

study consent process, which will focus on commitment to home practice, 
confidentiality, and openness to experience. MBSR is traditionally provided in a 
heterogeneous population, but studies have shown efficacy in homogenous 
populations. Mindfulness practice instruction will be offered during experiential parts 
of the sessions. Dyadic and group dialogue will be fostered, and didactic elements 
and group exercises will be presented. MBSR provides teachers flexibility in the 
curriculum structure and prioritizes effective use of the present moment; a general 
overview of session topics is below (Table 1).  
 
Table 1. Description of MSBR and Education Control sessions 
 
 
Ambulatory HRV and Actigraphy 
The day of the booster sessions a body-worn, Bluetooth-enabled, soft, flexible, 
water resistant patch (~2.5” x 1.3” x 0.2” medical grade silicone) with polarized 
electrodes (BioStamp nPoint, MC10), will be placed on the chest and will be used to 
collect ambulatory ECG and actigraphy measurements. The data will be recorded 
during the participant’s first and last booster session. The data may also be recorded 
during booster sessions in the even weeks of the intervention (weeks 2, 4, 6, and 8). . 
Patches will be programmed for both ECG and activity using a tablet-based mobile 
app.  Activity recordings will be used primarily for filtering and interpretation of 
HRV data. However, data will also be of interest in exploratory analyses of motor 
activity, restlessness and sleep migraine symptoms, including types of activity in 
different periods of the day and night (lying down, sitting, walking, total activity). 
 
Heartbeat Detection Task 
The Heartbeat Detection Task (HBDT) will be completed during the first and last 
booster sessions. Participants will be asked to count their heart beat during three 
varying time intervals (30s, 30s, 60s). In parallel, individuals’ heart-rate will be 
measured by Kardia Mobile technology. Participants will place their index and middle 
fingers of both hands-on top of the Kardia Mobile device and will be instructed to 
count their heartbeat for a period of 30 or 60 seconds. The readings from this device 
are linked to the Kardia Mobile App, which will be on a screen faced away from the 
Study Product Guidelines and Considerations​
31 of 68​Version 3.1 
​
​November 25th, 2024 
Week 
MBSR Session Content Focus 
Edu Ctl Session Content Focus 
1 
What is Mindfulness?  
 What is Nature? 
2 
Perception/ Beginner's Mind 
 The Natural World and the Mind 
3 
Mindful Movement  
 Confronting Fears of Nature 
4 
What is Stress? 
 How Can Nature Improve Health? (Pt. 1) 
5 
Coping with Stress 
 How Can Nature Improve Health? (Pt. 2)  
6 
Communication 
 Your Relationship with the Natural World  
Retreat 
Deepening Practice 
 Deepening Immersion in Nature 
7 
Cultivating Kindness 
 Caring about our Natural World 
8 
The Rest of Your Life 
 Setting up your Return to Nature Plan 

participant. Participant data stored in the Kardia Mobile app will be identified with 
the Study participant ID, which will not be linked to any identifying information. 
 
Intervention Questionnaires 
The following questionnaires will be given at specific points during the 
intervention, and will be given to both the MBSR and EduCtl Intervention groups: 
 
-​
Group Climate Questionnaire: This questionnaire will be administered at weeks 4 and 
8 of the intervention to evaluate perceived atmosphere of group environments in 
terms of engagement, positivity, and conflict.   
 
-​
Credibility Questionnaire: This questionnaire will be administered at weeks 1 and 8 of 
the intervention to measure the degree to which subjects’ find the treatment they are 
receiving to be credible and having the potential to be efficacious.   
 
5.3​
Concomitant Interventions  
5.3.1​ Allowed Interventions 
Enrolled participants will be screened for concomitant medications and are 
required to have been on stable doses for at least 30 days prior to starting the trial. 
They will also be asked to maintain medications/dosage regimes while participating 
in the trial.  
 
5.3.2​ Required Interventions 
Non-Applicable. 
5.3.3​ Prohibited Interventions 
Any participants with moderate or high levels of opioid use (>60mg Morphine 
equivalents) will be excluded from the study. Individuals that have current training or 
training in the past two years in mindfulness (MBCT, MBSR) or in the Relaxation 
Response or participants with relevant mindfulness meditation practice for an average 
of 10+ minutes a day in the past 3 months will be excluded from the study. However, 
if such interventions, though prohibited, are initiated during the study period, we will 
record this information but continue to collect outcome data. 
5.4​
Adherence Assessment  
Adherence will be defined as completing at least 5 out of the 9 group treatment 
sessions including the retreat. This will be confirmed by research assistants, who will 
attend all treatment visits and will verify and track participant attendance. Booster 
sessions can be made up at alternative times and do not count towards the 5 out of 9 
treatment session attendance requirement. Migraine subjects’ adherence to daily 
diaries will be deemed complete (i.e. no protocol deviation) if they perform at least 
75% of their diaries. Healthy subjects will be asked to complete 4 weeks of daily 
diaries but they are not required to reach 75% completion to continue in the study.   
 
Study Product Guidelines and Considerations​
32 of 68​Version 3.1 
​
​November 25th, 2024 

6. STUDY PROCEDURES  
6.1​
Schedule of Evaluations 
Assessment / 
Procedure 
Screening: 
Visit 1 (Day 
-42 to day 
-28) 
Daily diary 
run-in 
(Day-28 to 
Day 0) 
Baseline 
(fMRI-ANS-PE
T-MR) Visits 
2-4  (W1 to 
W2) 
Treatment 
Visits 5-20 
(W3 to W10) 
Post-Treatme
nt fMRI 
(fMRI-ANS-PE
T-MR) Visits 
21-23 (W11 to 
W12) 
3- and 
6-month 
Follow-up 
Informed Consent   
X* 
 
 
 
 
 
Demographics 
X* 
 
 
 
 
 
Medical history 
X* 
 
 
 
 
 
Inclusion/Exclusion 
Criteria 
X* 
 
 
 
 
 
Headache diary 
 
X* 
X* 
X 
X 
 
Pain ratings 
 
 
X* 
X 
X 
 
HIT6 
 
 
X 
 
X 
X 
MIDAS 
 
 
X 
 
X 
X 
MSQL 
 
 
X 
 
X 
 
PCS 
 
 
X* 
 
X 
X 
PROMIS-29  
 
 
X* 
 
X 
 
Perceived stress 
scale-14 
 
 
X* 
 
X 
 
BDI-II 
X* 
 
X* 
 
X 
 
Aura  
X* 
 
 
 
 
 
FFMQ  
 
 
X* 
 
X 
 
Freiburg-14 
 
 
X* 
 
X 
 
SCS-SF 
 
 
X* 
 
X 
 
MAIA 2 
 
 
X* 
 
X 
X 
DERS 
 
 
X* 
 
X 
 
HMSE 
 
 
X 
 
X 
X 
Brief Resilience  
scale 
 
 
X* 
 
X 
 
Study Product Guidelines and Considerations​
33 of 68​Version 3.1 
​
​November 25th, 2024 

Assessment / 
Procedure 
Screening: 
Visit 1 (Day 
-42 to day 
-28) 
Daily diary 
run-in 
(Day-28 to 
Day 0) 
Baseline 
(fMRI-ANS-PE
T-MR) Visits 
2-4  (W1 to 
W2) 
Treatment 
Visits 5-20 
(W3 to W10) 
Post-Treatme
nt fMRI 
(fMRI-ANS-PE
T-MR) Visits 
21-23 (W11 to 
W12) 
3- and 
6-month 
Follow-up 
Expectation for relief 
scale 
 
 
X* 
 
 
 
Widespread Pain 
Index 
 
 
X* 
 
X 
 
Measuring love and 
care for nature 
 
 
X* 
 
X 
 
The connectedness 
to nature scale 
 
 
X* 
 
X 
 
PET Recent Medical 
History Survey 
 
 
X* 
 
X 
 
Menstrual phase 
 
 
X* 
 
X 
 
fMRI screening form  
X* 
 
X* 
 
X 
 
PET safety form 
X* 
 
X* 
 
X 
 
Session attendance 
log 
 
 
 
X 
 
 
Concomitant 
medications 
X* 
X* 
X* 
X 
X 
X* 
Group Climate 
Questionnaire 
 
 
 
X 
 
 
Ambulatory 
ECG/Actigraphy 
 
 
 
X 
 
 
Credibility 
questionnaires 
 
 
 
X 
 
 
Adverse events 
 
 
X* 
X 
X 
 
​
 X* These procedures/items will also be completed by healthy controls in the study. 
 
6.2​
Description of Evaluations  
6.2.1​ Screening Evaluation 
Consenting Procedure 
Potential subjects interested in participating will be contacted by study staff in 
charge of enrollment. After explaining the study protocol, study staff will then ask for 
verbal consent before prescreening procedures are performed. Potential subjects will 
then answer a brief list of questions pertaining to inclusion/exclusion criteria, which 
may also be confirmed from the medical record. After completing the pre-screening 
process, they will be asked to come in for written informed consent and an initial 
screening visit.  
Study Product Guidelines and Considerations​
34 of 68​Version 3.1 
​
​November 25th, 2024 

The screening visit will begin with informed consent, which will be conducted by 
a Nurse Practitioner or MD.  The informed consent form will be an IRB approved 
form with language both specific to Partners Healthcare Research and the study 
protocol itself. Two copies of the consent form will be signed by both the patient and 
the study staff, one for each individual to keep. Documentation of signed consent and 
any modifications made will be logged and submitted for approval within the Partners 
Research IRB website. The subjects will be informed about the PET procedure and 
the risks associated with exposure to radiation and A-line, as well as risks of tVNS 
and behavioral treatments. They will be informed about minimal risks of routine high 
magnetic field and non-ionizing RF radiation involved in MR imaging.  Subjects will 
also be informed about small space within the magnet and noises made by switching 
gradients. Subjects will be informed that if they feel uncomfortable with the study, 
they can choose to terminate the study at any time.  They will be informed that their 
refusal to participate in the study or choosing to terminate it at some point will have 
no effect on care and treatment received by them at MGH now or in future. The 
subjects will be informed that their personal information will be protected as per the 
HIPAA guidelines. Before each testing session the participant will be told about the 
procedures for the experiment and we will only proceed if verbal assent is given. 
Patients will be given the time they desire to complete consent forms.  
Remote Consenting 
In order to comply with public health efforts to address COVID-19, informed 
consent may be obtained remotely. This will be done via electronic consent (e.g. 
Partners REDCap e-consent), or a remote consent process where the participant will 
be asked to sign the consent form and return back by email or mail. In either case, the 
consent discussion will occur identically to an in-person visit (as outlined above), but 
held over phone call using secure Cisco Jabber software or video conference. A 
physician member of the staff or a NP from the Clinical Translational Research Unit 
in the Charlestown Navy Yard will obtain this remote consent as well as a remote 
medical history (and migraine medical history for migraine participants) and 
documentation of concomitant medications. Following the informed consent process, 
a copy of the signed consent document will be provided to the patient (electronically 
if e-consent was used, and via mail if a physical copy).. The REDCap e-consent 
template being utilized is equivalent to written consent and is FDA compliant. As is 
with in-person consent, the study team will obtain and document informed consent 
before the participant is enrolled and any study procedures begin. All forms that 
cannot be completed electronically will be completed at the first in-person baseline 
visit instead. These screening forms include the MRI safety and PET safety forms, the 
physical, and the Modified Allen’s test. The saliva genotyping test will be mailed to 
participants during their daily diary eligibility period to minimize in-person visits. 
Screening 
Screening will take place within the first study visit of the trial, after informed 
consent. The participant will undergo a screening examination by the study staff, 
including: 
 
Study Product Guidelines and Considerations​
35 of 68​Version 3.1 
​
​November 25th, 2024 

●​ Demographic and socioeconomic questionnaires 
●​ MRI safety screening questionnaire 
●​ PET safety screening questionnaire 
●​ BDI-II 
●​ Aura Questionnaire 
●​ Concomitant medication questionnaire 
●​ Participants will be review instructions about how to complete the daily 
diaries and information about aura with migraines.  
●​ MD/NP will review Inclusion/Exclusion criteria 
●​ MD/NP will perform medical history and physical, modified Allen’s test, and 
blood/saliva draw (PBR affinity test) 
●​ PBR affinity test: Unless patients have been previously genotyped for the 
Ala147Thr TSPO polymorphism (during the course of our previous 
experiments), either venous blood (up to 10 ml) or a saliva sample will be 
collected at the Screening Visit from all subjects considered for potential 
participation in a [11C]PBR28 scan in order to have them genotyped for the 
Ala147Thr polymorphism in the TSPO gene (rs6971). Due to COVID-19, the 
saliva kit may be mailed to the participant after the Screening visit is 
complete. Participants will complete the test at home and mail it back to study 
staff. Participants found to be low affinity binders will still be considered 
eligible for behavioral testing and fMRI scanning, but will not complete the 
study’s PET-MR imaging component. If the participant agrees to an A-line 
and after the PBR affinity test is found to have the genotype and unable to 
complete the PET-MR, they will be notified within their 4 weeks leading up to 
the baseline visits.  
 
 
6.2.2​ Enrollment, Baseline, and/or Randomization 
​Enrollment 
Upon completing informed consent and passing the screening eligibility criteria, 
participants will be enrolled in the study. This date will be considered the enrollment 
date and will be recorded and kept in the enrollment log.  
Following the screening visit, subjects (migraine patients and healthy controls) 
will complete daily morning and evening online electronic diaries to chronicle any 
experience with migraine headaches or pain for 4 weeks. These diaries will include 
daily assessment of migraine headache, severity, perceived trigger, medication use, 
sleep quality, and other related symptoms. These diaries will allow us to assess 
whether headache frequency and severity of migraine patients is indeed consistent 
with our inclusion / exclusion criteria as well as provide a source for baseline 
measures that can be used for clinical outcomes. Electronic diaries will be 
administered using StudyTRAX.  Study participants will receive reminders to open a 
link to their personal StudyTRAX account.  When participants click the link on their 
phone’s home screen (placed there under supervision of research assistants during the 
screening visit), they will open the daily diary within their account. A research 
Study Product Guidelines and Considerations​
36 of 68​Version 3.1 
​
​November 25th, 2024 

assistant will monitor the StudyTRAX database for daily diary completion and 
subjects will have remuneration incentive to complete as many diaries as possible.   
 
​
Text Message Communication 
Participants will be asked at the phone screen if they consent to receiving 
unencrypted text messages. Participants will be asked again at the screening visit to 
reconfirm their consent. Participant consent will be documented on REDCap. 
Subjects will be able to opt out of receiving text messages at any time throughout 
their study participation. Text messages will only be sent for appointment reminders, 
scheduling confirmation, and daily diary reminders.   
 
Pre-intervention Assessments 
Upon confirming patient eligibility after the 4-week daily diary run-in period 
(between 4 and 20 headache days for migraine patients), subjects will attend a series 
of 3 pre-intervention evaluations within a period of 3 weeks including: 
●​ Pre-intervention fMRI assessment: a pre-therapy assessment to compare with 
post-outcomes after the patient’s undergoes the 8-week intervention period.  
Each fMRI scanning session will take approximately 3 hours and subjects 
will be in the scanner for up to 2 hours. Participants will be exposed to a 
forehead stimulation task (non-painful trigeminal nerve branch stimulation to 
the forehead) similar to our previously validated experimental model 91 in 
order to assess fMRI hyperexcitability in the brainstem and higher brain 
regions. This location targets the ophthalmic (V1) spinal trigeminal nerve 
branch. Stimulation will be delivered to the subjects using a block fMRI 
design. After the fMRI experiment, the intensity of sensations during the scan 
will be rated by subjects on a numerical rating scale (NRS) of 0 to 10 (0: no 
sensation, 10: pain detection threshold, i.e. on the verge of painful sensation). 
We have used a similar standardized stimulation procedure in previous 
IRB-approved protocols (#2016P001009). This task will be repeated before 
and after a RAVANS tVNS stimulation fMRI scan run. Additionally, 
structural and resting state fMRI scans will be collected. 
During the fMRI session we may employ a breath-holding task during one 
of the scans.  CO2 is a potent vasodilator of the cerebrovasculature and can 
be used to test the responsiveness of the autoregulatory system in migraine 
patients.  The outcome of the cerebrovascular reactivity using breath-holding 
methods has been shown to be comparable with 5% CO2 inhalation 92.  
Subjects will be instructed to have breath-holding and normal breathing 
paced by visual cue.  The paradigm consists of 2 consecutive phases (normal 
breathing and breath-holding) repeating 5 times.  The normal breathing phase 
Study Product Guidelines and Considerations​
37 of 68​Version 3.1 
​
​November 25th, 2024 

will last no less than 60 seconds, while the breath-holding phase lasts 30 
seconds or less. The phases will be paced by the software Presentation 
(Neurobehavioral Systems) and the task will last 10 minutes. The participant 
will be told to stop if there is any complaint of respiratory discomfort, chest 
pain, or neurologic symptoms. Participants will also be asked to refrain from 
smoking for at least 3 hours prior to procedure. 
 
●​ Pre-Intervention PET/MR assessment: Prior to the scan session, subjects will 
be asked to provide a saliva sample for a toxicology screen. If the results of 
this test show the presence of drugs that were not previously disclosed and 
that could interfere with the trial (such as substances of abuse) or with the 
PET scan, then the subject may be dropped from the study after consultation 
with a staff physician. The toxicology screen includes testing for the 
following kinds of drugs: alcohol, cocaine, cannabis, opioids (including 
oxycodone and fentanyl), amphetamines, methamphetamines, phencyclidine, 
benzodiazepines, barbiturates, and methadone. The results of the toxicology 
testing, while documented in the research records, will not be entered into 
participants’ medical record/chart. 
At the beginning of the scan session, an intravenous catheter will be 
placed in the participant’s antecubital vein of the left or right arm, prior to 
going to the scanning area. The radioligand [11C]PBR28 will be used to 
determine whether patients with migraine exhibit evidence of glial activation. 
During IV placement, up to 10mL of blood may be drawn to test complete 
blood count, serum chemistries, interleukins, and TNF-alpha. Female 
participants of childbearing age will also be asked to have ~5mL of their 
blood drawn in order to perform a serum pregnancy test or complete a urine 
sample pregnancy test on the day of the scan (blood will be sent to the core 
lab for super stat testing). Participants that do not receive the PET injection 
(due to genotype or other personal reasons) will not have blood drawn or 
urine sample for pregnancy.. The presence of antibodies will be used to 
explore the possible effects of prior exposure to the coronavirus on 
neuroinflammation, in exploratory analyses. Up to 10 ml of blood will be 
drawn for both healthy volunteers and migraine patients. This testing will be 
performed through a third party vendor or through the MGH core lab. 
Furthermore, blood pressure, pulse, and body temperature will be measured 
to document the presence of a fever or any other abnormalities with the 
subject that could present a risk for their safety in the scanner. 
If the participant opted for an arterial line, it will be placed in a radial 
artery with local anesthesia (20 or 18 gauge cannula, 2-5 ml of lidocaine 1% 
intradermal and subcutaneous) using sterile techniques, if the participant has 
Study Product Guidelines and Considerations​
38 of 68​Version 3.1 
​
​November 25th, 2024 

consented to this procedure. The placement of an arterial line will be 
presented as optional to the participants, and we will ask for the participants’ 
consent each time. The arterial line will be placed in the arm contralateral to 
the intravenous line that is used for the [11C]PBR28 radiotracer injection. The 
arterial line will enable blood sampling (1mL to 12mL) at various times 
during the imaging study for at most 154mL of blood. The collected arterial 
blood will be used to compute metabolite-corrected arterial input function for 
kinetic modeling analyses. The catheter will be placed by an experienced 
staff physician (i.e., board-certified anesthesiologist, fully licensed anesthesia 
resident, or certified registered nurse anesthetist), monitored throughout and 
accessed by an experienced research nurse. Residents will be eligible as long 
as they are at least half way through PGY2 year and have completed a 
cardiac anesthesia rotation, have a full license, are personally approved for 
proficiency by the residency program director, and they operate under the 
supervision of an attending. Either a physician or a nurse practitioner will 
discontinue the catheter at the end of the study visit.  
In addition, participants will be exposed to a sensory/affective stressor 
(IAPS task) during this visit. The IAPS task uses a large set of standardized, 
emotionally-evocative, internationally-accessible, color photographs that 
includes contents across a wide range of semantic categories. The IAPS is 
being developed and distributed by the Center for Emotion and Attention 
(CSEA) at the University of Florida. It is highly validated and has been 
shown to reliably elicit autonomic responses and self-reported valence and 
arousal ratings from male and female subjects 93-99. The images will be 
presented in a block fMRI designs.  
During the scan, participants will also complete an interoception task 
where they will be asked to focus on the sensation of their heart, lungs, sight, 
and sound. After focusing on these areas, participants will be asked how 
strongly they felt each sensation. 
After the scan session, participants will complete the Motion Coherency 
Task. They will sit in front of a computer screen and will be presented with 
white moving dots. A group of these dots will move coherently either toward 
the center or away from the center. The rest of dots will move randomly. 
Participants are expected to look at a fixation object, presented at the center 
of screen, and to report the direction of coherently moving dots (toward vs. 
away from the center) by pressing one of the two keys on the keyboard. 
Response time and accuracy are both important and will be measured during 
the experiment. Each test will start with few practice trials (< 20 trials) 
during which the participant will become familiar with the stimuli and task. 
Study Product Guidelines and Considerations​
39 of 68​Version 3.1 
​
​November 25th, 2024 

The overall test (including the practice trials) is expected to take between 
5-10 minutes. 
In most cases, this visit will require up to 6 hours for completion: ~45 min 
for preparation, ~30 min for A-line placement, if applicable, ~120 min for 
scanning procedures and ~60 min for filling out questionnaires and 
observation, plus an additional ~1.5 hr to perform pregnancy test in women 
of childbearing age.  
 
●​ Pre-Intervention autonomic (ANS) assessment: This visit will take 
approximately 3 hours and will include the collection of electrocardiography 
(ECG), skin conductance level (SCL), and respiration data at 500 Hz using an 
MRI-compatible, noninvasive BIOPAC MP150 system (BIOPAC Systems, 
Goleta, California) or Chart Data Acquisition Software (ADInstruments, 
Colorado Springs, CO) on a laptop. The following tests will be performed for 
evaluation of cardiac autonomic function in the subjects included in the 
study: 
 
a) Paced Breathing Task. Subjects sit quietly while pacing their 
breathing with the aid of visual cues on a computer screen as in 100.  
Three different paces within the traditional HRV HF and LF 
frequency ranges will be used (0.2, 0.25, and 0.3 Hz) for 3 minutes 
each (9 minutes in total). This test measures the vagally-mediated 
responses to changes in breathing rates 101-104. 
b) Sit-stand Test. Three minutes after the paced breathing task, a 
sit-stand test (5 min duration) will be performed. The hemodynamic 
response to standing is a commonly performed measure of autonomic 
function105-108. Active standing causes an abrupt increase in heart rate 
that peaks at approximately 3s followed by a more gradual increase 
that peaks at approximately 12s after standing. Heart rate and blood 
pressure return to a new baseline after approximately 30s. The ‘30:15 
ratio’ assesses the ratio of the heart rate increase that occurs 15s after 
standing relative to 30s after standing. 
 
c) Quantitative Sensory Testing (QST), including: 
●​ Mechanical pain: Responses to punctate mechanical stimuli 
will be measured using a standard set of weighted probes that 
provide estimates of pain threshold and mechanical temporal 
summation. Series of 10 stimuli (with 1-second inter-stimulus 
intervals) will be used to assess the temporal summation of 
pain that occurs with rapid administration of identical stimuli. 
Study Product Guidelines and Considerations​
40 of 68​Version 3.1 
​
​November 25th, 2024 

A Wagner pressure algometer will be utilized to assess 
responses to pressure stimulation at several anatomical sites. 
Pain pressure thresholds (PPT) will be determined twice at 
each of the following sites on the right and left sides of the 
body: the medial fat pad of the trapezius and frontalis. 
Mechanical pressure will be applied using a 0.5-cm2 probe 
covered with 1mm polypropylene pressure-transducing 
material; pressure is increased at a steady rate of 30 kPA/s until 
the subject indicates that the pressure has become painful. 
Participants are informed that they may terminate the 
procedure at any time. 
●​ Cold Pain Assessment:  Responses to noxious cold will be 
evaluated using a repeated cold pressor task (CPT), which 
involves immersion of the  hand in a circulating water bath 
(Arctic Series) maintained at a temperature of 8°C. This test 
has been used to investigate autonomic response in stress, the 
relationship between psychological disorders and autonomic 
responsivity, as well as cortical influences on autonomic 
function101,102,109-115. Participants will undergo a series of three 
cold pressor tasks, with the first 2 consisting of serial 
immersions of the  hand for 15 sec, with 2 min between 
immersions. Conditioned Pain Modulation (CPM, which refers 
to the phenomenon of one noxious stimulus inhibiting the pain 
of a second noxious stimulus) is measured during these 2 cold 
pressor trials by assessing PPTh during the immersion. The 
pressure pain threshold assessment will be done twice on the 
trapezius. The 3rd and final CPT involves an immersion of the 
hand lasting until a participant reaches pain tolerance (or a 3 
min maximum). Participants will rate the intensity of the cold 
pain on a 0-100 scale (“no pain” to “most intense pain 
imaginable”) every 15 sec. 
In addition, the following validated psychometric assessments will be 
administered before the autonomic testing session: 
-​
Headache Impact Test-6 (HIT-6)116: assessment of 
headache-related disability 
-​
1-month Migraine Disability Assessment (MIDAS)117: 
assessment of headache-related disability 
-​
Migraine Specific Quality of Life Questionnaire, version 
2.1118: assessment of quality of life 
-​
Pain Catastrophizing Scale 119: measures pain-related 
Study Product Guidelines and Considerations​
41 of 68​Version 3.1 
​
​November 25th, 2024 

Rumination, Magnification and Helplessness 
-​
Patient Reported Outcomes Measurement Information System 
(PROMIS-29): a 29-item used to assess patient-reported health status 
for physical function, anxiety, depression, fatigue, sleep disturbance, 
ability to participate in social roles and pain.120:  
-​
Perceived Stress Scale121: PSS-14 stress assessment 
-​
Five Facet Mindfulness Questionnaire122: mindfulness 
assessment  
-​
Freiburg Mindfulness Inventory – 14-question mindfulness 
assessment. 
-​
Short-form Self-Compassion Scale (SCS-SF) 123: an 
abbreviated 12-item form of the original 26-item Self-Compassion 
Scale.   
-​
Multidimensional Assessment of Interoceptive Awareness 
(MAIA 2) 124: a 37-item self-report scale designed to assess multiple 
aspects of interoception and interoceptive awareness.   
-​
Difficulties in Emotion Regulation (DERS) Scale 125: a 
36-item self-report scale designed to assess emotional dysregulation.   
-​
Headache Management Self-Efficacy Scale126: self-efficacy 
assessment  
-​
Brief Resilience Scale: a 6-question assessment of resilience 
-​
Expectation of Relief: measures the extent to which subjects 
expect the treatment to relieve their migraine pain 
-​
Demographics form asking for participants’ gender, race, 
ethnicity, sexual orientation, socioeconomic data (annual household 
income), and languages spoken. 
-​
Widespread Pain Index: assessment of pain across the body127 
-​
Measuring love and care for nature128 
-​
The connectedness to nature scale129 
​Remote Questionnaires  
All questionnaires typically collected during the in-person screening visit or 
behavioral visit may be collected remotely, as they are already completed on secure 
online platforms (i.e. StudyTrax) with built in identification systems to ensure they 
are completed by the subject. This will minimize the safety risks between participants 
and study staff due to the COVID-19. All other procedures for the screening visit 
including the physical and modified Allen’s test, will be completed at the first 
in-person visit. All other procedures for the behavioral visit including the Autonomic 
Assessment, Paced Breathing Task, Sit-Stand Task, and Quantitative Sensory Testing 
will be completed at the in-person behavioral visit.   
 
Study Product Guidelines and Considerations​
42 of 68​Version 3.1 
​
​November 25th, 2024 

Pain Ratings 
Before and after each Baseline visit, Booster visit, and Post-Treatment visit, 
participants will be asked about their headache pain, non-headache pain, and anxiety. 
These questions will be on a scale from 0 to 100, where 0 is no pain and 100 is the 
worst pain imaginable.  
Randomization 
Patients will be randomized before completing their pre-intervention evaluations. 
This will be at least 4 weeks after their screening visit, and after it has been 
determined that the participant’s frequency of migraines is within the range specified 
in our inclusion/exclusion criteria (between 4 and 20 headache days per month). 
Study staff conducting the pre-intervention assessments will be blinded to the 
treatment arm assignment. 
 
6.2.3​ Blinding 
All patients and study staff will be blinded, except for the study coordinator and 
the statistician, who will execute the randomization scheme, and Cambridge Health 
Alliance (CHA) study staff directly involved in the delivery of this behavioral 
intervention (i.e. MM trainers). Outcome assessment will be performed by blinded 
personnel. For RAVANS administration at home practice sessions, the study 
coordinator will program the stimulation devices to active or sham stimulation 
according to each subject allocation. The device instructions and display will be the 
same for active and sham groups, with the only difference being that subjects in the 
sham arm will not receive electrical stimulation. Subjects in the sham group will also 
be told that stimulation will be at a fixed level and that they “may or may not feel 
anything at the ear”. 
The blind will be unlocked only after the last subject has completed their 
participation and the database is locked. The recruitment and the randomization order 
will be maintained by the research coordinator and study staff. Information regarding 
the blind will be kept in a secure file, accessible by this staff member.  
 
6.2.4​ Treatment Visits 
Sixteen treatment visits will be performed in the 8 weeks following the completion of 
pre-intervention evaluations. Measurements and procedures in each visit will include:  
●​
Visits 5-20: 
▪​
MBSR or Education control intervention 
▪​
RAVANS tVNS or Sham tVNS intervention 
▪​
Session attendance log 
▪​
Concomitant medications questionnaire 
▪​
Credibility questionnaire (Weeks 1 and 8 only) 
▪​
Group climate questionnaire (Weeks 4 and 8 only) 
▪​
Adverse events form 
▪​
Headache diaries 
▪​
Ambulatory ECG and Actigraphy measurements 
▪​
Pain ratings 
Study Product Guidelines and Considerations​
43 of 68​Version 3.1 
​
​November 25th, 2024 

 
6.2.5​ Post-intervention Evaluation 
Final evaluations will be performed in visits 21-23 and will include the following 
procedures: 
●​
Post-treatment fMRI session: 
▪​
fMRI safety form 
▪​
fMRI scan (including forehead, RAVANS tVNS stimulation, and 
breath-hold task) 
▪​
Concomitant medications questionnaire  
▪​
Recent medical history survey 
▪​
Adverse events form 
▪​
Headache diaries 
▪​
Menstrual phase questionnaire 
▪​
Pain ratings 
 
●​
Post-treatment PET-MR session: 
▪​
PET-MR safety form 
▪​
fMRI safety form 
▪​
Menstrual phase questionnaire 
▪​
Beck Depression Inventory-II 
▪​
PET-MR scan (including IAPS task and interoception task) 
▪​
Motion Coherency Task 
▪​
Concomitant medications questionnaire  
▪​
PET recent medical history survey 
▪​
Adverse events form 
▪​
Headache diaries 
▪​
Pain ratings 
▪​
Participants will be given: Post PBR28 Instructions and Post Arterial Line 
Instructions (if applicable) 
 
●​
Post-treatment ANS session: 
▪​
Behavioral questionnaires (including HIT6, MIDAS, MSQL, PCS, 
PROMIS-29, Perceived stress scale, BDI-II,  FFMQ, Freiburg-14, 
SCS-SF, MAIA-2, DERS, SECD-6, HMSE, Brief Resilience Scale, WPI, 
Love and Care for Nature, Connectedness to Nature) 
▪​
Autonomic tasks (including paced breathing, sit/stand test, QST) 
▪​
Concomitant medications questionnaire  
▪​
Recent medical history survey 
▪​
Adverse events form 
▪​
Headache diaries 
▪​
Pain ratings 
 
6.2.6​ 3- and 6-month Follow-up (home-based Patient Reported Outcomes): 
●​ Questionnaires (including HIT6, MIDAS, PCS, PROMIS-29, HMSE, 
Concomitant medications questionnaire) 
Study Product Guidelines and Considerations​
44 of 68​Version 3.1 
​
​November 25th, 2024 

 
7. SAFETY ASSESSMENTS  
7.1​
Specification of Safety Parameters 
fMRI, PET-MR safety considerations 
The FDA considers investigations of fMRI software and hardware operating 
within FDA specific parameters as non-significant risk device studies. All studies will 
adhere to these (non-significant risk) FDA approved safety levels for the Siemens 
system. These safety parameters include static magnetic field, time varying magnetic 
fields (dB/dt), specific absorption rate (SAR), and acoustic noise levels. Risks already 
established for fMRI include claustrophobia due to confinement of the patient in the 
system, the malfunction of electromagnetic implants caused by interaction with the 
magnetic fields, projectiles and tissue burns caused by metallic tattoos or implants, 
pregnancy, surface burns due to interaction of metallic system components or surface 
adhesives with the patients skin, slight hearing impairment due to high acoustic noise 
levels generated by the system, and slight neuromuscular twitching (for the higher 
field strength systems). However, system safeguards have been designed and 
operating guidelines have been provided to minimize any of the aforementioned risks. 
 
PET-MR safety considerations 
The FDA recently gave the first regulatory clearance of a hybrid PET-MR 
scanner in the U.S. An intravenous catheter will be placed for this study. The subject 
will feel a slight pinprick, similar to a bee sting, and may feel some discomfort and 
have some bruising or bleeding at the site where the needle goes in. Depending on the 
length of time the catheter is in place, a bruise may last for a day or so. Rarely an 
infection may occur at this site.  If infection does occur, it will be treated. Also, for 
participants who agree to an arterial line each time, an intra-arterial catheter will be 
placed by an anesthesiologist, on the arm opposite of the radioligand injection line, 
for blood draws during the PET study (1-2ml of 1% lidocaine will be injected as 
needed to numb the area). Local infection, swelling, and redness could occur at the 
sites of line placement, as well as temporary loss of pulse at the wrist. This area may 
have a bruise or feel uncomfortable for 2-3 days after the catheter is removed. The 
risks associated with having blood drawn include: bruising, local discomfort, or 
infection at the site of the needle puncture. Rarely an infection may occur at this site, 
and if an infection does occur, it will be treated. Inserting an arterial line (A-line) can 
hurt more than having a regular IV or having blood drawn with a needle. We will 
place the A-line under local anesthesia (i.e., lidocaine), which may cause an allergic 
reaction. Even if we numb the wrist area first, the insertion may still hurt. Once the 
A-line is in place, it usually does not hurt. We will ask subjects not to take triptan or 
ergotamine related drugs (dihydroergotamine, or Cafergot, or sumatriptan etc.) 72 
hours before the PET visit.  Refraining from taking these medications could increase 
the risk of pain and discomfort from headache. If the headache pain becomes worse 
Study Product Guidelines and Considerations​
45 of 68​Version 3.1 
​
​November 25th, 2024 

and the subject needs to use these kinds of medications within 72 hours prior to the 
PET visit, we will reschedule the visit if possible. Other medications such as Tylenol 
and other over-the-counter pain medications will be allowed.  
 
 
The subject may experience: 
  
●​ Pain, bleeding, swelling or redness at the wrist. This could mean infection, but 
infection is rare (less than 1 in 100) and can be treated. 
●​ Short loss of pulse at the wrist if blood flow in the artery is briefly stopped 
(for example, because of a clot or spasm of the artery). 
●​ Damage to the artery wall or nearby nerves. 
●​ Catheter breaking or falling out. 
 
There have been reports of decreased blood flow to the hand, which resulted in 
the need for surgery. This is very rare and has not been reported when catheters have 
been in place for only a few hours for research. 
 
After the catheter has been removed by MD or NP: 
●​ We will ask the subject to stay for at least 30 minutes so we can check on 
him/her. 
●​ The subject may have a bruise or feel tenderness for 2-3 days around the area 
where the catheter was placed. 
●​ We will instruct the subject to avoid lifting anything heavier than a small bag 
of flour for a day. 
●​ Approximately 24 hours after the beginning of the imaging procedures, we 
will give the subject a phone call to determine whether he or she is 
experiencing study related issues. 
●​ We will instruct the subject to call us if: 
▪​
Bleeding occurs after the subject leaves (rare).  
▪​
The wrist area is painful or red or swollen. 
 
At least a Nurse Practitioner and a Registered Nurse will be present for at least 30 
minutes following radiotracer injection.  
 
The radiation exposure in this study will be small and there is no evidence that it 
represents a major health risk. If subjects have participated in other research studies in 
the past 12 months that have involved radiation exposure, they will be asked to inform 
the investigators or study staff (by writing initials on the consent form verifying that 
they have not been exposed to other radiation in the past 12 months). If it is 
determined that their prior radiation exposure exceeds our current guidelines, it is 
possible that they will not be allowed to participate in this study.   
 
Study Product Guidelines and Considerations​
46 of 68​Version 3.1 
​
​November 25th, 2024 

We will use [11C]PBR28 produced by the cyclotron/radiochemistry/ 
radiopharmacy facility at the A. A. Martinos Center for Biomedical Imaging. The 
Radioligand injection will be administered by a licensed Nuclear Medicine 
Technologist.  Should there be an adverse event during PET/MR, Drs. Hadjikhani or 
Loggia will be responsible for communicating with the IRB within the stipulated time 
frame.  Steve Stufflebeam, MD, PhD, is a radiologist and will review any abnormal 
results that are discovered on the images and refer subjects for follow-up and treatment 
if needed. 
 
Mindfulness Meditation Safety considerations 
The mindfulness training intervention given in this study is a behavioral 
intervention and can be considered minimal risk. The main risk is of increased 
psychological discomfort, due to increased attention to unpleasant thoughts, feelings 
or body sensations that can lead to an increase in undesirable feelings. Since 
commonly encountered psychological discomforts will be discussed as a regular part 
of trainings (e.g. noticing the frequency of negative thoughts or emotions, becoming 
aware of unusual habits or thought patterns, etc.), some participants may experience 
psychological discomfort during discussions. The trained therapist has extensive 
experience with minimizing discomfort in patient populations going through this 
training. 
 
Educational Control Intervention risks 
The control intervention given in this study is a behavioral intervention and can 
be considered minimal risk. The main risk is of increased psychological discomfort, 
due to increased attention to unpleasant images, that can lead to an increase in 
undesirable feelings. The trained therapist has experience minimizing discomfort in 
patient populations going through this training. 
 
Virtual Group Visit Risks 
Patients will attend group sessions virtually, using a computer-based video 
conferencing computer application. Video conferencing risks include an increased 
expense from cellular carrier if participants have a limited data plan and rely on a 
mobile data, instead of home internet, for videoconferencing. All internet-based 
technology, like the mobile application, is open to eavesdropping. Because of this we 
have made every effort to reduce the chance of outside people gaining access to 
protected data. The system is very secure with updated security protection technology, 
but no system is perfectly secure. 
 
RAVANS tVNS Stimulation risks 
There is a small possibility of slight and temporary discomfort at the site where 
the electrodes are placed. Potential vaso-vagal reactions to stimulation resulting in 
dizziness or light-headedness will be promptly recognized and treated by a study 
physician or clinically-trained personnel with prompt removal of the electrodes and 
repositioning the subject into a supine position. In some subjects, the experience of 
electrical stimulation may cause anxiety. Subjects will be required to remain under 
supervision until all symptoms subside. A study physician will be available at all times 
Study Product Guidelines and Considerations​
47 of 68​Version 3.1 
​
​November 25th, 2024 

to discuss the study with subjects should they become concerned. The electrical 
stimulation procedure is without significant safety concerns. The electrical stimulator, 
checked by MGH Biomedical Engineering, has a current limiter preventing harmful 
stimulation levels. Further, during the electrical stimulation, we will be closely 
monitoring that the current received by the subject is well tolerated. Throughout the 
measurement sessions, participants will be repeatedly asked if they are well and 
comfortable. Should the subject feel any discomfort he or she will be advised to let the 
researcher know and the stimulation will be immediately interrupted. Subjects will be 
trained at the first booster session on the use of the device at home and study personnel 
will be available by phone or video in case subjects present any question or concern. 
In addition, log stimulation files extracted from the device will be assessed weekly by 
unblinded study personnel to assess compliance and the appropriate use of the device. 
 
Breath-Hold Task risks  
No serious risks are associated with the levels and durations of CO2 to be induced 
in the breath hold task.  Elevated PCO2 can sometimes cause light headedness during 
breath holding and shortness of breath immediately after breath holding.  These 
symptoms are also time-limited and resolve spontaneously without need for medical 
treatment. Most importantly, the subjects have the full control to restore normal 
breathing whenever they wish. 
   
Sensory Testing risks  
There may be increased pain from some of the sensory tests (QST). The increased 
pain will usually decrease and go away within minutes. There is a slight chance of 
mild transient bruising associated with use of the probes or algometer. In our 
experience, this is quite rare (< 5 % of cases). Electrode gel used for stimulation and 
monitoring may cause minor skin irritation that would resolve within a few days. 
 
7.2​
Methods and Timing for Assessing, Recording, and Analyzing Safety 
Parameters 
We will follow our institutional and NIH policies for reporting adverse events. As the 
study intervention is minimally invasive and generally safe (i.e. tVNS), the safety 
profile for this study is not high risk. 
7.3​
Adverse Events and Serious Adverse Events  
An adverse event (AE) is generally defined as any unfavorable and unintended 
diagnosis, symptom, sign (including an abnormal laboratory finding), syndrome or 
disease which either occurs during the study, having been absent at baseline, or if 
present at baseline, appears to worsen. Adverse events are to be recording regardless 
of their relationship to the study intervention.   
A serious adverse event (SAE) is generally defined as any untoward medical 
occurrence that results in death, is life threatening, requires inpatient hospitalization 
or prolongation of existing hospitalization, results in persistent or significant 
disability/incapacity, or is a congenital anomaly. 
Study Product Guidelines and Considerations​
48 of 68​Version 3.1 
​
​November 25th, 2024 

Examples of adverse events for this study would be dizziness, nausea, headache 
resulting from tVNS stimulation and pain, swelling or bruising resulting from the 
A-line from the PET/MRI scan, however safeguards have been put in place to 
minimize the risk of such events.  
All SAEs will be confirmed in the participant’s electronic medical record. If the 
participant does not have a MGB record, study staff will inquire with the participant 
and ask for documentation (e.g., patient portal, discharge summary, doctor’s note, 
etc.).  
7.4​
Reporting Procedures 
In accordance with Partners Healthcare Research Committee regulations, all 
unanticipated problems including serious adverse events will be reported within 5 
working days/7 calendar days. In the case of SAEs, copies of the written follow-up 
report will also be sent to the PHRC office as well as any additional follow-up 
evaluations. The investigator will report for up to one month all SAE’s that occur 
after a subject has discontinued or completed the study.  
Non-serious adverse events will be reported in writing to PHRC. All AEs, SAEs, 
and protocol deviations will be kept in logs in the study’s regulatory binder.  
In addition, since this is an IND regulated study (IND#142546 for the use of 
[11C]PBR28 to assess neuroinflammation with PET imaging), reporting procedures 
will be in  compliance with the Federal Food, Drug, and Cosmetic Act (FDCA) (21 
U.S.C. 301 et. seq.) as well as the implementing regulations [Title 21 of the Code of 
Federal Regulations (CFR)]. These procedures will include 
o​ Reporting any unexpected fatal or life-threatening suspected reactions to the 
FDA no later than 7 calendar days after initial receipt of the information.  [21 
CFR 312.32(c)(2)].  
o​ Reporting any (1) serious, unexpected suspected adverse reactions, (2) 
findings from other clinical , animal, or in-vitro studies that suggest 
significant human risk, and (3) a clinically important increase in the rate of a 
serious suspected adverse reaction to the FDA and to all investigators no later 
than 15 calendar days after determining that the information qualifies for 
reporting [21 CFR 312.32(c)(1)]. 
o​ Submitting annual progress reports within 60 days of the anniversary of the 
date that the IND became active (the date the clinical study was permitted to 
begin) [21 CFR 312.33]. 
 
7.5​
Follow-up for Adverse Events 
All AEs and SAEs will be monitored until resolution. Additionally, subjects 
whom have experienced an AE will be followed up with one month following the 
event.  
Study Product Guidelines and Considerations​
49 of 68​Version 3.1 
​
​November 25th, 2024 

7.6​
Safety Monitoring  
​
An independent Data and Safety Monitoring Board, forming the Independent 
Monitoring Committee (IMC), will be organized for all proposed research. The 
DSMB for this study will be a 3-member multidisciplinary group whose members 
include a neurologist, a pain researcher, and a statistician; Drs. Zev Schuman-Olivier 
and Bruce Rosen will coordinate these DSMB interactions. All adverse event 
reporting will be coordinated by Dr. Schuman-Olivier who, as noted, will be informed 
of any adverse events immediately after or during their occurrence. Regular meetings 
will be held annually; however, in the event of severe adverse events, Dr. 
Schuman-Olivier and the committee will convene immediately. 
8. INTERVENTION DISCONTINUATION  
Intervention will be discontinued for subjects who: 
o​ Experience AEs that interfere with study completion  
o​ Are unable to complete study visits 
o​ Cannot follow protocol 
o​ Are deemed unable to continue the trial based on judgement of the PI 
Possible reasons for discontinuation are: 
o​ Inability to understand questionnaires/study protocol 
o​ Claustrophobia 
o​ Scheduling conflict 
o​ Concomitant medications 
 
9. STATISTICAL CONSIDERATIONS  
9.1​
General Design Issues  
We will employ a multi-modal approach to evaluate the effects on migraine 
pathophysiology following MM and RAVANS tVNS. We will apply fMRI, PET, and 
H-MRS neuroimaging at baseline and following 8-weeks of therapy in a 2x2 
randomized longitudinal trial design with groups receiving RAVANS or sham tVNS, 
and MM training or education control. Following screening and 4 weeks of daily 
migraine diary completion and baseline behavioral/ANS and PET/MRI sessions, a 
total of N=96 episodic migraine patients will be randomized considering a 15% 
attrition rate for the goal of N=96 migraine participants in 4 N=24 groupsPatients will 
return post-therapy for PET/MRI and behavioral/ANS evaluation.  
Our primary outcomes are the longitudinal treatment group contrasts (post-treatment 
vs baseline) among Migraineurs in the following variables: 
- Cortical amplification ratio to trigeminal afference as assessed by fMRI 
(specifically, pINS to Sp5 fMRI percent signal change). 
 
- HF-HRV response to sensory/affective stressor. 
  
- [11C]PBR28 PET ligand binding in pINS 
Study Product Guidelines and Considerations​
50 of 68​Version 3.1 
​
​November 25th, 2024 

 
Our secondary outcomes are the baseline contrasts between Migraineurs and healthy 
controls in the aforementioned variables. 
  
9.2​
Sample Size and Randomization 
Study outcomes will be evaluated using a similar statistical approach (generalized 
linear model) with identical contrasts. As such, they share similar power calculations 
for their primary outcomes. These power calculations were conducted using the ‘pwr’ 
and ‘pwrFDR’ packages in R and are presented below: 
 
Primary Outcomes: Longitudinal treatment group contrasts among Migraineurs 
​
Assuming 15% attrition after randomly allocating N = 96 individuals in a 1:1 
fashion to each study arm (n = 24), an evaluable group of individuals with migraine 
(N = 96; n = 24/arm), with a two-tailed alpha = 0.05, a moderate correlation between 
pre-treatment and post-treatment scores (i.e., r = 0.50), and using pairwise 
between-groups contrasts, the study will have power = 0.80 to detect an effect size as 
small as d ≥ 0.86 after adjustment for all six possible comparisons across intervention 
arms using a false discovery rate (FDR) of 0.10.  
 
Secondary Outcomes: Baseline contrasts between Migraineurs and Healthy Controls 
​
Assuming an evaluable (i.e., excluding attrition) group of individuals with 
migraine (N = 96) and healthy controls (N = 50, considering a 50% attrition rate for 
healthy controls), with a two-tailed alpha = 0.05, and a between-groups GLM 
contrast, the study will have power = 0.80 to detect an effect size as small as d ≥ 0.65.  
For each of the projects, the observed pilot data exhibited large effect sizes (ranging 
from d ~ 0.90 to 1.2) that will be sufficiently powered given the proposed sample 
size. 
 
9.2.1 Treatment Assignment Procedures 
To reduce the chances of sampling bias, defined narrowly as systematic 
differences across randomized groups, we will employ a modified version of 
covariate adaptive randomization. In covariate adaptive randomization, a new 
participant is sequentially assigned to a particular treatment group by considering 
specific covariates and previous assignments of participants. However, in this study, 
individuals must be enrolled in the nearest temporal cohort in relation to their 
screening. To accommodate this fact, each pool of currently eligible individuals will 
each be scored based on their potential to balance the experimental groups, 
conditional on previous assignments and their characteristics. Assignments will be 
based on a solution that places the maximum number of individuals currently under 
consideration into the current cohort while assigning the fewest possible to the next 
cohort (i.e., a two-variable optimization). This is important as any delay from when 
subjects express desire to enroll in the study and actually receiving therapy (at 
absolute minimum, the time would already be 1 month of daily diaries plus 3 weeks 
of MRI/PET scan and behavioral sessions), impacts dropout. Thus, at worst subjects 
would join the next group cohort and the method of minimization will be used to 
Study Product Guidelines and Considerations​
51 of 68​Version 3.1 
​
​November 25th, 2024 

reduce the difference in groups if the current participant was assigned to the current 
group or the next available group. The variable considered for balance will be 
monthly headache frequency.  
9.3 ​
Definition of Populations 
​
Care will be taken to reduce the manual corruption of data, but it is inevitable that 
certain data will be corrupted (e.g., equipment failure), missing (e.g., attrition), or 
excluded due to a priori designations (e.g., poor treatment compliance). A full 
accounting of data will be recorded in all cases and included in the reports of the 
analyses. Readers of the research reports will be specifically informed of the enrolled 
samples/patients and the amount of missing data for any reason. Where appropriate, 
attempts will be made to examine the impact of missing data on the analyses.  
​
A modified intention to treat (mITT) philosophy will be applied to the primary 
analyses for participants enrolled in the clinical trial. Any participant who is enrolled, 
randomized, is observed for the baseline testing session, and engages in a single 
treatment session will be incorporated into the mITT analysis set. A per protocol (PP) 
set will also be designated as those individuals who complete all testing sessions as 
well as complete their treatment assignment.  
​
To account for missing data in either analysis set, an imputation strategy will be 
utilized that is appropriate to the extent of missing data. The PP set, by definition, will 
exhibit missing data only due to corruption of measurements or equipment failure. 
Thus, it is expected that missing data will be very limited, and if <15% of total 
measurements, will be viewed as missing completely at random and ignored in the 
analysis. If missing data >=15%, multiple imputation strategies will be used to 
estimate missing variable distributions from which to generate unbiased inferences. 
For the mITT set, we will rely on techniques recommended by White et al. (2011) 
including adjusted analyses relying on multiple imputation (MI) and inverse 
probability weighting (IPTW). For both the MI and IPTW models, we will examine 
the pattern of missing data for evidence of violations of the missing at random 
assumption (e.g., headache frequency progression leading to enhanced drop-out). 
9.4​
Interim Analyses and Stopping Rules 
There are no interim analyses planned for this clinical trial. Although the data will 
be monitored by the PIs for safety outcomes, and the DSMB will be provided with 
summary level data, no formal superiority or futility analyses will be conducted prior 
to the completion of the study. When the enrollment targets have been met, the plan 
of analysis will be conducted as outlined below.  
9.5​
Outcomes  
9.5.1​ Primary Outcomes   
 
Project 1: 
- Effects of combined MM + RAVANS tVNS on brainstem and cortical response to 
trigeminal sensory afference in migraine patients 
Longitudinal analyses will use post-treatment amplification ratio contrasted 
Study Product Guidelines and Considerations​
52 of 68​Version 3.1 
​
​November 25th, 2024 

between the four treatment arms using a generalized linear model. This model will 
evaluate post-treatment levels of cortical amplification ratio to trigeminal afference as 
the dependent variable, treatment group main effect as the predictor, and baseline 
amplification ratio as a covariate (i.e., an ANCOVA). A statistically significant main 
effect will be interpreted as evidence that treatment assignment induces a differential 
change in amplification ratio. These changes will be further evaluated using planned 
contrasts designed to evaluate the impact of group assignment in Bonferroni corrected 
pairwise contrasts. 
 
                   Project 2: 
- Effects of combined MM +RAVANS tVNS on peripheral parasympathetic activity of 
migraine patients​ ​
 
​ ​ Longitudinal analyses will use post-treatment HF-HRV response to 
sensory/affective stressor contrasted between the four treatment arms using a 
generalized linear model. This model will evaluate post-treatment HF-HRV response 
as the dependent variable, treatment group main effect as the predictor, and baseline 
HF-HRV response as a covariate (i.e., an ANCOVA). A statistically significant main 
effect will be interpreted as evidence that treatment assignment induces a differential 
change in HF-HRV response. These changes will be further evaluated using planned 
contrasts designed to evaluate the impact of group assignment in Bonferroni corrected 
pairwise contrasts. 
 
Project 3: 
- Effects of combined MM +RAVANS tVNS on neuroinflammation in migraine 
patients  
​ ​ Longitudinal analyses will use post-treatment PET [11C]PBR28 SUVR signal 
contrasted between the four treatment arms using a generalized linear model. This 
model will evaluate post-treatment [11C]PBR28 SUVR signal in the posterior insula 
as the dependent variable, treatment group main effect as the predictor, and baseline 
pIns SUVR as a covariate (i.e., an ANCOVA). A statistically significant main effect 
will be interpreted as evidence that treatment assignment induces a differential change 
in PET signal. These changes will be further evaluated using planned contrasts 
designed to evaluate the impact of group assignment in Bonferroni corrected pairwise 
contrasts. 
 
9.5.2​ Secondary Outcomes   
Project 1: 
- Differences in cortical amplification ratio and habituation in response to trigeminal 
sensory afference between migraine patients and healthy controls 
The cortical amplification ratio to trigeminal afference at baseline will be 
contrasted between the MIG and HC using a generalized linear model (GLM) with 
the amplification ratio as the dependent variable (and appropriate link function) and 
migraine group (MIG vs HC) as a fixed factor. Habituation ratios for all subjects will 
be calculated by linear fit for individual fMRI response estimates over 11 stimulus 
blocks modeled as continuously scaled fixed effects. The slopes will be evaluated 
using the same GLM as the primary outcome. 
Study Product Guidelines and Considerations​
53 of 68​Version 3.1 
​
​November 25th, 2024 

 
- Glutamate levels in MIG and longitudinal response to MM + tVNS and association 
in trigeminal afference response with neurotransmitter concentration 
The analysis plan will use a LCModel incorporating a voxel-wise analysis with 
H-MRS-derived maps of Glx (combined glutamate and glutamine) concentration, as 
analyzed by GLM. An additional model will examine an amplification x habituation 
interaction term in predicting glutamate response. 
 
Project 2: 
- Differences in HF-HRV response to sensory/affective stressors between migraine 
patients and healthy controls 
The HF-HRV response to sensory/affective stressor at baseline will be contrasted 
between the MIG and HC using a generalized linear model (GLM) with the HF-HRV 
response as the dependent variable (and appropriate link function) and migraine 
group (MIG vs HC) as a fixed factor. 
 
- Central autonomic network (CAN) response to sensory/affective stressors in 
migraine patients and its response to combined MM + RAVANS tVNS  
Using amygdala and other CAN regions’ (i.e., insula, MCC and mPFC) response 
to negative images (in a region-of-interest analysis), we will test for group differences 
between migraineurs and HCs using GLM as described above. We will also test for 
treatment group differences between migraineurs using GLM as described above. 
 
- Relationship between CAN activation and peripheral parasympathetic response to 
sensory/affective stressors in migraine patients and its response to combined MM + 
RAVANS tVNS  
Post-treatment changes in amygdala response will be regressed on PRE-POST 
change in HF-HRV during IAPS provocation with negative images in migraine 
patients receiving MM and/or RAVANS tVNS. Using PRE and POST data in 
migraine patients from the 3 active interventions, we will test for association between 
PRE-POST change in amygdala response and PRE-POST change in HF-HRV during 
negative image presentation using GLM. The same analyses will be conducted for 
neutral images, and for other brain regions within the CAN. 
 
Project 3: 
- Differences in neuroinflammation levels between migraine patients and healthy 
controls 
The [11C]PBR28 SUVR maps and fALFF-slow 4 maps at baseline will be 
contrasted between the MIG and HC using a generalized linear model (GLM) with 
[11C]PBR28 SUVR maps or fALFF-slow 4 maps as the dependent variable (and 
appropriate link function) and migraine group (MIG vs HC) as a fixed factor. In a 
secondary analysis, we will use an alternative strategy to remove the effect of 
potential confounders (age, sex and genotype) that may not be fully statistically 
corrected for. In this case, a subset of migraine patients, from the available pool of 96 
patients recruited in the study, will be identified and compared with the controls in a 
matched pairs design, in which each patient will be matched to a TSPO 
Study Product Guidelines and Considerations​
54 of 68​Version 3.1 
​
​November 25th, 2024 

polymorphism-, age- and sex-matched control subject. The differences between these 
matched pairs on baseline [11C]PBR28 SUVR and fALFF-slow maps will be 
evaluated using GLM.  
9.6​
Data Analyses  
All of the analyses conducted under the aims and hypotheses for all projects will 
be conducted using the generalized linear model. This approach allows flexibility in 
modeling the outcome distributions using link functions (e.g., normal, log-normal) 
while maintaining the statistical power of a parametric approach. Additionally, using 
this approach over a non-parametric equivalent, allows the estimation of the adjusted 
models, formal statistical interaction, and allows for the study of individual change. 
Each of the primary, secondary, and adjusted models will be conducted utilizing 
the experimental groups and manipulations as fixed effects. For example, one set of 
comparisons evaluates the participants with migraine versus healthy controls (Mig vs 
HC). For models involving individual change (i.e., longitudinal models) across the 
four experimental groups, group assignment will be entered as a fixed effect, with 
baseline levels of the outcome variable entered as a covariate, and the post-therapy 
measurements will be specified as an outcome using a link function appropriate to 
distribution under study. This approach is analogous to an ANCOVA for which 
Vickers & Altman (2001) illustrate as being very advantageous when there is at least 
a modest within-individual correlation between measurement occasions. When a 
statistically significant main effect is observed, protected post hoc testing will be 
conducted to contrast the impact of each treatment to examine the additive (single 
modality treatments) and interactive (both treatments combined) in relation to each 
other. The adjusted models will be conducted in the same way but with an additional 
covariate entered into the model to adjust the associations for baseline migraine 
severity (number of headache days per month).  
Several of the outcomes examine the association between interval-scaled fixed 
effects, and these will also be conducted using generalized linear models. For these 
models, the outcome of interest (or change in the outcome of interest) will be 
regressed on the predictor of interest (or change in the predictor of interest). 
Estimating the associations using this approach allows for flexible outcome 
distributions, additional covariates in the adjusted models, and produces association 
metrics in the original units of the variables under study. 
All analyses will be conducted using the most recent version of R and R studio. 
Given our commitment to conducting reproducible analyses, we will utilize the R 
language to capitalize on its advanced capabilities for generating publication quality 
outputs that allow a reader to evaluate the results and the code that produced them. 
There are several methods that are primarily used to make analyses verifiable and 
more transparent  
(see: https://cran.rproject.org/web/views/ReproducibleResearch.html). Each of the 
analyses will be disseminated to the investigators using these data driven documents. 
 
Study Product Guidelines and Considerations​
55 of 68​Version 3.1 
​
​November 25th, 2024 

10. DATA COLLECTION AND QUALITY ASSURANCE 
10.1​ Data Collection Forms  
Data will be collected by the study staff who will also be operating the MRIs. 
These individuals will be blinded to treatment allocation. Questionnaires will be 
completed and stored electronically using the StudyTRAX database.  
10.2​ Data Management  
All participant records and information are de-identified and given a code in order 
to protect patient confidentiality. All electronic records will be secured within the 
Partners password protected StudyTRAX database. All written records will be kept in 
a coded folder, filed and locked away.  
 
Dr. Tohyama at the University of Toronto and Dr. Brusaferri at London South 
Bank University will access data from the current study using remote linux machines 
and MGB Dropbox. The data will include imaging from positron emission 
tomography / magnetic resonance imaging (PET-MR) and/or MRI imaging and 
demographic data (i.e., information such as age, binding affinity, and scan date). All 
participant information will be labeled with a study code such as mig001.  
 
In the research consent form, participants will be prompted to give their 
permission for us to share their samples and health information for other research. 
Data will only be shared for those participants that indicate “yes” to the question, “Do 
you agree to let us store and use your samples and health information for other 
research related to chronic pain?”. 
 
10.3​ Quality Assurance  
10.3.1​ Training 
All study staff have undergone MRI safety training and lead MRI operators have 
passed a certification exam to operate the magnet. All members of the study staff are 
CITI certified and have been trained to follow Good Clinical Practice (GCP). 
Additionally, study staff have undergone radiation safety training through the 
Massachusetts General Hospital Radiation Department. 
10.3.2​ Quality Control Committee  
QC for all data will be completed by research assistants to ensure accurate 
completion and imaging data quality. 
10.3.3​ Metrics 
We will use verified head motion QC metrics including frame displacement and 
root-mean-square measures for all imaging data. 
Study Product Guidelines and Considerations​
56 of 68​Version 3.1 
​
​November 25th, 2024 

10.3.4​ Protocol Deviations 
All protocol deviations are documented in the deviation log and are reported 
during scheduled Continuing Reviews through the Partners IRB Committee.  
10.3.5​ Monitoring 
Monitoring will be performed as needed by the institution and NIH oversight 
personnel. 
 
11. PARTICIPANT RIGHTS AND CONFIDENTIALITY  
11.1​
Institutional Review Board (IRB) Review  
This study protocol and informed consent documents and all 
amendments/modifications will be submitted and reviewed by the Partners Human 
Research Committee IRB.  
11.2​
Informed Consent Forms 
Study staff will have two copies of the Informed Consent on hand, one for 
themselves and one for the subject. They will go through each portion of the form 
with the subject and answer any questions before obtaining written consent. The 
subject and the study staff will sign, date, and time both documents. Fluency in 
English is an inclusion criterion, and subjects will need to be able to understand all 
study procedures in order to be eligible for the trial. Therefore, the subject must be 
able to read through the form with the study staff and provide their own written 
consent.  
11.3​
Participant Confidentiality  
Any data, specimens, forms, reports, video recordings, and other records that 
leave the site will be identified only by a participant identification number 
(Participant ID, PID) to maintain confidentiality. All records will be kept in a locked 
file cabinet. All computer entry and networking programs will be done using PIDs 
only. Information will not be released without written permission of the participant, 
except as necessary for monitoring by IRB, the FDA, the NCCIH, and the OHRP 
11.4​
Study Discontinuation  
The study may be discontinued at any time by the IRB, the NCCIH, the OHRP, 
the FDA, or other government agencies as part of their duties to ensure that research 
participants are protected.  
11.5​
Virtual Group Visits 
We have established a relationship with the HIPAA-compliant Zoom 
videoconferencing solution (https://zoom.us/). Zoom provides HD video and voice 
conferencing as well as resistance to video-freezing. All videos are protected with 
Secure Socket Layer (SSL) while in transit, using AES 128-bit encryption. Access is 
Study Product Guidelines and Considerations​
57 of 68​Version 3.1 
​
​November 25th, 2024 

controlled by establishing a “Host” of each Zoom meeting. The meeting will start and 
end exactly when the “Host” (the instructor) enters and leaves the meeting. Meetings 
are represented by unique URLs generated by the Zoom API at the instructor’s 
discretion. The “Join link,” which allows a participant to join the meeting, is sent 
from the study staff to the Participant at the time of meeting creation through Partners 
secure email. Participants will receive a new password each week to access the group 
meeting.  
Furthermore, the host can (and must) explicitly allow or disallow access to 
anyone attempting to enter the meeting. As part of the fidelity measurement, the 
sessions will be recorded to allow for 10% of all video encounters to be assessed for 
quality assurance. The center of the intervention, the Center for Mindfulness and 
Compassion, currently owns the appropriate hardware and software components for 
the use of Zoom. 
 
12. COMMITTEES 
Non applicable 
 
13. PUBLICATION OF RESEARCH FINDINGS  
Study findings will be published in compliance with all institutional and journal 
policies. 
 
14. REFERENCES  
1​
Smitherman, T. A., Burch, R., Sheikh, H. & Loder, E. The prevalence, impact, and 
treatment of migraine and severe headaches in the United States: a review of 
statistics from national surveillance studies. Headache 53, 427-436, 
doi:10.1111/head.12074 (2013). 
2​
Murray, C. J. et al. Disability-adjusted life years (DALYs) for 291 diseases and 
injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of 
Disease Study 2010. Lancet 380, 2197-2223, doi:10.1016/S0140-6736(12)61689-4 
(2012). 
3​
Hu, X. H., Markson, L. E., Lipton, R. B., Stewart, W. F. & Berger, M. L. Burden of 
migraine in the United States: disability and economic costs. Arch Intern Med 159, 
813-818 (1999). 
4​
Schwedt, T. J., Chiang, C.-C., Chong, C. D. & Dodick, D. W. Functional MRI of 
migraine. The Lancet. Neurology 14, 81-91, doi:10.1016/s1474-4422(14)70193-0 
(2015). 
5​
Sprenger, T. & Borsook, D. Migraine changes the brain: neuroimaging makes its 
mark. Curr Opin Neurol 25, 252-262, doi:10.1097/WCO.0b013e3283532ca3 (2012). 
Study Product Guidelines and Considerations​
58 of 68​Version 3.1 
​
​November 25th, 2024 

6​
Borsook, D., Burstein, R. & Becerra, L. Functional imaging of the human trigeminal 
system: opportunities for new insights into pain processing in health and disease. 
Journal of neurobiology 61, 107-125, doi:10.1002/neu.20085 (2004). 
7​
Abanoz, Y., Abanoz, Y., Gunduz, A. & Savrun, F. K. Trigeminal somatosensorial 
evoked potentials suggest increased excitability during interictal period in patients 
with long disease duration in migraine. Neuroscience letters 612, 62-65, 
doi:10.1016/j.neulet.2015.11.045 (2016). 
8​
Noseda, R. & Burstein, R. Migraine pathophysiology: anatomy of the 
trigeminovascular pathway and associated neurological symptoms, CSD, 
sensitization and modulation of pain. Pain 154 Suppl 1, 
doi:10.1016/j.pain.2013.07.021 (2013). 
9​
Stankewitz, A. & May, A. Increased limbic and brainstem activity during migraine 
attacks following olfactory stimulation. Neurology 77, 476-482, 
doi:10.1212/WNL.0b013e318227e4a8 (2011). 
10​
Burstein, R., Yamamura, H., Malick, A. & Strassman, A. M. Chemical stimulation 
of the intracranial dura induces enhanced responses to facial stimulation in brain 
stem trigeminal neurons. Journal of neurophysiology 79, 964-982 (1998). 
11​
Lee J et al. Reduced insula habituation associated with amplification of trigeminal 
brainstem input in migraine Cephalalgia, in press (2016). 
12​
Coppola, G., Di Lorenzo, C., Schoenen, J. & Pierelli, F. Habituation and 
sensitization in primary headaches. The journal of headache and pain 14, 65, 
doi:10.1186/1129-2377-14-65 (2013). 
13​
Burstein, R., Noseda, R. & Borsook, D. Migraine: multiple processes, complex 
pathophysiology. The Journal of neuroscience : the official journal of the Society for 
Neuroscience 35, 6619-6629, doi:10.1523/jneurosci.0373-15.2015 (2015). 
14​
Koenig, J., Williams, D. P., Kemp, A. H. & Thayer, J. F. Vagally mediated heart rate 
variability in headache patients--a systematic review and meta-analysis. Cephalalgia 
36, 265-278, doi:10.1177/0333102415583989 (2016). 
15​
Peroutka, S. J. Migraine: a chronic sympathetic nervous system disorder. Headache 
44, 53-64, doi:10.1111/j.1526-4610.2004.04011.x (2004). 
16​
Cui, Y. et al. 11C-PK11195 PET for the In Vivo Evaluation of Neuroinflammation in 
the Rat Brain After Cortical Spreading Depression. J Nucl Med 50, 1904-1911, 
doi:10.2967/jnumed.109.066498 (2009). 
17​
Argoff, C. E., Albrecht, P., Irving, G. & Rice, F. Multimodal analgesia for chronic 
pain: rationale and future directions. Pain Med 10 Suppl 2, S53-66, 
doi:10.1111/j.1526-4637.2009.00669.x (2009). 
18​
Chang, K. L., Fillingim, R., Hurley, R. W. & Schmidt, S. Chronic pain management: 
nonpharmacological therapies for chronic pain. FP Essent 432, 21-26 (2015). 
19​
Dale, R. & Stacey, B. Multimodal Treatment of Chronic Pain. Med Clin North Am 
100, 55-64, doi:10.1016/j.mcna.2015.08.012 (2016). 
20​
Institute of Medicine.   The National Academies Collection: Reports funded by 
National Institutes of Health   (2011). 
21​
Hilton, L. et al. Mindfulness Meditation for Chronic Pain: Systematic Review and 
Meta-analysis. Ann Behav Med, doi:10.1007/s12160-016-9844-2 (2016). 
22​
Gu, J., Strauss, C., Bond, R. & Cavanagh, K. How do mindfulness-based cognitive 
therapy and mindfulness-based stress reduction improve mental health and 
Study Product Guidelines and Considerations​
59 of 68​Version 3.1 
​
​November 25th, 2024 

wellbeing? A systematic review and meta-analysis of mediation studies. Clin Psychol 
Rev 37, 1-12, doi:10.1016/j.cpr.2015.01.006 (2015). 
23​
Edwards, R. R., Dworkin, R. H., Sullivan, M. D., Turk, D. C. & Wasan, A. D. The 
Role of Psychosocial Processes in the Development and Maintenance of Chronic 
Pain. J Pain 17, T70-92, doi:10.1016/j.jpain.2016.01.001 (2016). 
24​
Edwards, R. R., Calahan, C., Mensing, G., Smith, M. & Haythornthwaite, J. A. 
Pain, catastrophizing, and depression in the rheumatic diseases. Nat. Rev. Rheumatol 
(2011). 
25​
Kabat-Zinn, J. An outpatient program in behavioral medicine for chronic pain 
patients based on the practice of mindfulness meditation: theoretical considerations 
and preliminary results. General Hospital Psychiatry 4, 33-47, 
doi:10.1016/0163-8343(82)90026-3 (1982). 
26​
Cherkin, D. C. et al. Two-Year Follow-up of a Randomized Clinical Trial of 
Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual 
Care for Chronic Low Back Pain. JAMA 317, 642-644, doi:10.1001/jama.2016.17814 
(2017). 
27​
Cherkin, D. C. et al. Effect of Mindfulness-Based Stress Reduction vs Cognitive 
Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in 
Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA 315, 
1240-1249, doi:10.1001/jama.2016.2323 (2016). 
28​
Morone, N. E., Greco, C. M. & Weiner, D. K. Mindfulness meditation for the 
treatment of chronic low back pain in older adults: a randomized controlled pilot 
study. Pain 134, 310-319, doi:10.1016/j.pain.2007.04.038 (2008). 
29​
Reiner, K., Tibi, L. & Lipsitz, J. D. Do mindfulness-based interventions reduce pain 
intensity? A critical review of the literature. Pain Med 14, 230-242, 
doi:10.1111/pme.12006 (2013). 
30​
Morone, N. E. et al. A Mind-Body Program for Older Adults With Chronic Low 
Back Pain: A Randomized Clinical Trial. JAMA Intern Med 176, 329-337, 
doi:10.1001/jamainternmed.2015.8033 (2016). 
31​
Tonelli, M. E. & Wachholtz, A. B. Meditation-based treatment yielding immediate 
relief for meditation-naïve migraineurs. Pain management nursing : official journal 
of the American Society of Pain Management Nurses 15, 36-40, 
doi:10.1016/j.pmn.2012.04.002 (2014). 
32​
Wells, R. E. et al. Meditation for migraines: a pilot randomized controlled trial. 
Headache 54, 1484-1495, doi:10.1111/head.12420 (2014). 
33​
Bakhshani, N. M., Amirani, A., Amirifard, H. & Shahrakipoor, M. The 
Effectiveness of Mindfulness-Based Stress Reduction on Perceived Pain Intensity 
and Quality of Life in Patients With Chronic Headache. Glob J Health Sci 8, 
142-151, doi:10.5539/gjhs.v8n4p142 (2015). 
34​
Zeidan, F. & Vago, D. R. Mindfulness meditation-based pain relief: a mechanistic 
account. Ann N Y Acad Sci 1373, 114-127, doi:10.1111/nyas.13153 (2016). 
35​
Zeidan, F. et al. Mindfulness-Meditation-Based Pain Relief Is Not Mediated by 
Endogenous Opioids. J Neurosci 36, 3391-3397, 
doi:10.1523/JNEUROSCI.4328-15.2016 (2016). 
36​
Zeidan, F. et al. Mindfulness Meditation-Based Pain Relief Employs Different 
Neural Mechanisms Than Placebo and Sham Mindfulness Meditation-Induced 
Study Product Guidelines and Considerations​
60 of 68​Version 3.1 
​
​November 25th, 2024 

Analgesia. J Neurosci 35, 15307-15325, doi:10.1523/JNEUROSCI.2542-15.2015 
(2015). 
37​
Zeidan, F. et al. Brain mechanisms supporting the modulation of pain by 
mindfulness meditation. J Neurosci 31, 5540-5548, 
doi:10.1523/JNEUROSCI.5791-10.2011 (2011). 
38​
Dickenson, J., Berkman, E. T., Arch, J. & Lieberman, M. D. Neural correlates of 
focused attention during a brief mindfulness induction. Soc Cogn Affect Neurosci 8, 
40-47, doi:10.1093/scan/nss030 (2013). 
39​
Doll, A. et al. Mindful attention to breath regulates emotions via increased 
amygdala-prefrontal cortex connectivity. Neuroimage 134, 305-313, 
doi:10.1016/j.neuroimage.2016.03.041 (2016). 
40​
Farb, N. A. S., Segal, Z. V. & Anderson, A. K. Mindfulness meditation training 
alters cortical representations of interoceptive attention. Social cognitive and 
affective neuroscience 8, 15-26, doi:10.1093/scan/nss066 (2013). 
41​
Euston, D. R., Gruber, A. J. & McNaughton, B. L. The role of medial prefrontal 
cortex in memory and decision making. Neuron 76, 1057-1070, 
doi:10.1016/j.neuron.2012.12.002 (2012). 
42​
Fayed, N. et al. Brain changes in long-term zen meditators using proton magnetic 
resonance spectroscopy and diffusion tensor imaging: a controlled study. PLoS One 
8, e58476, doi:10.1371/journal.pone.0058476 (2013). 
43​
Kelly, C. J., Huang, M., Meltzer, H. & Martina, M. Reduced Glutamatergic 
Currents and Dendritic Branching of Layer 5 Pyramidal Cells Contribute to Medial 
Prefrontal Cortex Deactivation in a Rat Model of Neuropathic Pain. Front Cell 
Neurosci 10, 133, doi:10.3389/fncel.2016.00133 (2016). 
44​
McCracken, L. M. & Vowles, K. E. Acceptance and commitment therapy and 
mindfulness for chronic pain: model, process, and progress. Am. Psychol 69, 178-187 
(2014). 
45​
Grant, J. A. & Rainville, P. Pain sensitivity and analgesic effects of mindful states in 
Zen meditators: a cross-sectional study. Psychosom Med 71, 106-114, 
doi:10.1097/PSY.0b013e31818f52ee (2009). 
46​
Gard, T. et al. Pain attenuation through mindfulness is associated with decreased 
cognitive control and increased sensory processing in the brain. Cereb Cortex 22, 
2692-2702, doi:10.1093/cercor/bhr352 (2012). 
47​
Perlman, D. M., Salomons, T. V., Davidson, R. J. & Lutz, A. Differential effects on 
pain intensity and unpleasantness of two meditation practices. Emotion 10, 65-71, 
doi:10.1037/a0018440 (2010). 
48​
Brown, C. A. & Jones, A. K. Meditation experience predicts less negative appraisal 
of pain: electrophysiological evidence for the involvement of anticipatory neural 
responses. Pain 150, 428-438, doi:10.1016/j.pain.2010.04.017 (2010). 
49​
Zunhammer, M., Eichhammer, P. & Busch, V. Do cardiorespiratory variables 
predict the antinociceptive effects of deep and slow breathing? Pain Med 14, 
843-854, doi:10.1111/pme.12085 (2013). 
50​
Busch, V. et al. The effect of deep and slow breathing on pain perception, autonomic 
activity, and mood processing--an experimental study. Pain Med 13, 215-228, 
doi:10.1111/j.1526-4637.2011.01243.x (2012). 
Study Product Guidelines and Considerations​
61 of 68​Version 3.1 
​
​November 25th, 2024 

51​
Zeidan, F., Gordon, N. S., Merchant, J. & Goolkasian, P. The effects of brief 
mindfulness meditation training on experimentally induced pain. J Pain 11, 199-209, 
doi:10.1016/j.jpain.2009.07.015 (2010). 
52​
Reiner, K., Granot, M., Soffer, E. & Lipsitz, J. D. A Brief Mindfulness Meditation 
Training Increases Pain Threshold and Accelerates Modulation of Response to 
Tonic Pain in an Experimental Study. Pain Med 17, 628-635, doi:10.1111/pme.12883 
(2016). 
53​
MacCoon, D. G. et al. The validation of an active control intervention for 
Mindfulness Based Stress Reduction (MBSR). Behav Res Ther 50, 3-12, 
doi:10.1016/j.brat.2011.10.011 (2012). 
54​
Kingston, J., Chadwick, P., Meron, D. & Skinner, T. C. A pilot randomized control 
trial investigating the effect of mindfulness practice on pain tolerance, psychological 
well-being, and physiological activity. J Psychosom Res 62, 297-300, 
doi:10.1016/j.jpsychores.2006.10.007 (2007). 
55​
Liu, X., Wang, S., Chang, S., Chen, W. & Si, M. Effect of brief mindfulness 
intervention on tolerance and distress of pain induced by cold-pressor task. Stress 
Health 29, 199-204, doi:10.1002/smi.2446 (2013). 
56​
Sharon, H. et al. Mindfulness Meditation Modulates Pain Through Endogenous 
Opioids. Am J Med 129, 755-758, doi:10.1016/j.amjmed.2016.03.002 (2016). 
57​
Zgierska, A. E. et al. Mindfulness Meditation and Cognitive Behavioral Therapy 
Intervention Reduces Pain Severity and Sensitivity in Opioid-Treated Chronic Low 
Back Pain: Pilot Findings from a Randomized Controlled Trial. Pain Med 17, 
1865-1881, doi:10.1093/pm/pnw006 (2016). 
58​
Cash, E. et al. Mindfulness meditation alleviates fibromyalgia symptoms in women: 
results of a randomized clinical trial. Ann Behav Med 49, 319-330, 
doi:10.1007/s12160-014-9665-0 (2015). 
59​
Grant, J. A. Meditative analgesia: the current state of the field. Ann N Y Acad Sci 
1307, 55-63, doi:10.1111/nyas.12282 (2014). 
60​
Grant, J. A., Courtemanche, J. & Rainville, P. A non-elaborative mental stance and 
decoupling of executive and pain-related cortices predicts low pain sensitivity in Zen 
meditators. Pain 152, 150-156, doi:10.1016/j.pain.2010.10.006 (2011). 
61​
Marchand, W. R. Mindfulness-based stress reduction, mindfulness-based cognitive 
therapy, and Zen meditation for depression, anxiety, pain, and psychological 
distress. J Psychiatr Pract 18, 233-252, doi:10.1097/01.pra.0000416014.53215.86 
(2012). 
62​
Deen, M. et al. Serotonergic mechanisms in the migraine brain - a systematic review. 
Cephalalgia : an international journal of headache, doi:10.1177/0333102416640501 
(2016). 
63​
Richter, F., Mikulik, O., Ebersberger, A. & Schaible, H. G. Noradrenergic agonists 
and antagonists influence migration of cortical spreading depression in rat-a 
possible mechanism of migraine prophylaxis and prevention of postischemic 
neuronal damage. Journal of cerebral blood flow and metabolism : official journal of 
the International Society of Cerebral Blood Flow and Metabolism 25, 1225-1235, 
doi:10.1038/sj.jcbfm.9600120 (2005). 
64​
Magis, D. Neuromodulation in migraine: state of the art and perspectives. Expert 
review of medical devices 12, 329-339, doi:10.1586/17434440.2015.1005606 (2015). 
Study Product Guidelines and Considerations​
62 of 68​Version 3.1 
​
​November 25th, 2024 

65​
Schoenen, J., Roberta, B., Magis, D. & Coppola, G. Noninvasive neurostimulation 
methods for migraine therapy: The available evidence. Cephalalgia : an 
international journal of headache, doi:10.1177/0333102416636022 (2016). 
66​
Aston-Jones, G. et al. Afferent regulation of locus coeruleus neurons: anatomy, 
physiology and pharmacology. Prog Brain Res 88, 47-75 (1991). 
67​
Van Bockstaele, E. J., Peoples, J. & Telegan, P. Efferent projections of the nucleus of 
the solitary tract to peri-locus coeruleus dendrites in rat brain: evidence for a 
monosynaptic pathway. The Journal of comparative neurology 412, 410-428 (1999). 
68​
Hord, E. D., Evans, M. S., Mueed, S., Adamolekun, B. & Naritoku, D. K. The effect 
of vagus nerve stimulation on migraines. The journal of pain : official journal of the 
American Pain Society 4, 530-534 (2003). 
69​
Mosqueira, A. J. et al. [Vagus nerve stimulation in patients with migraine]. Revista 
de neurologia 57, 57-63 (2013). 
70​
Yuan, H. & Silberstein, S. D. Vagus Nerve Stimulation and Headache. Headache, 
doi:10.1111/head.12721 (2015). 
71​
Lance, J. W., Lambert, G. A., Goadsby, P. J. & Duckworth, J. W. Brainstem 
influences on the cephalic circulation: experimental data from cat and monkey of 
relevance to the mechanism of migraine. Headache 23, 258-265 (1983). 
72​
Ayata, C. Cortical spreading depression triggers migraine attack: pro. Headache 50, 
725-730, doi:10.1111/j.1526-4610.2010.01647.x (2010). 
73​
Chen, S. P. et al. Vagus nerve stimulation inhibits cortical spreading depression. 
Pain 157, 797-805, doi:10.1097/j.pain.0000000000000437 (2016). 
74​
Fahy, B. G. Intraoperative and perioperative complications with a vagus nerve 
stimulation device. Journal of clinical anesthesia 22, 213-222, 
doi:10.1016/j.jclinane.2009.10.002 (2010). 
75​
Nomura, S. & Mizuno, N. Central distribution of primary afferent fibers in the 
Arnold's nerve (the auricular branch of the vagus nerve): a transganglionic HRP 
study in the cat. Brain Res. 292, 199-205 (1984). 
76​
Kiyokawa, J., Yamaguchi, K., Okada, R., Maehara, T. & Akita, K. Origin, course 
and distribution of the nerves to the posterosuperior wall of the external acoustic 
meatus. Anatomical science international 89, 238-245, doi:10.1007/s12565-014-0231-4 
(2014). 
77​
Ventureyra, E. C. Transcutaneous vagus nerve stimulation for partial onset seizure 
therapy. A new concept. Childs Nerv Syst 16, 101-102, doi:10.1007/s003810050021 
(2000). 
78​
Frangos, E., Ellrich, J. & Komisaruk, B. R. Non-invasive Access to the Vagus Nerve 
Central Projections via Electrical Stimulation of the External Ear: fMRI Evidence 
in Humans. Brain Stimul 8, 624-636, doi:10.1016/j.brs.2014.11.018 (2015). 
79​
Dietrich, S. et al. [A novel transcutaneous vagus nerve stimulation leads to 
brainstem and cerebral activations measured by functional MRI]. Biomedizinische 
Technik. Biomedical engineering 53, 104-111, doi:10.1515/bmt.2008.022 (2008). 
80​
Kraus, T. et al. CNS BOLD fMRI effects of sham-controlled transcutaneous 
electrical nerve stimulation in the left outer auditory canal - a pilot study. Brain 
Stimul 6, 798-804, doi:10.1016/j.brs.2013.01.011 (2013). 
81​
Straube, A., Ellrich, J., Eren, O., Blum, B. & Ruscheweyh, R. Treatment of chronic 
migraine with transcutaneous stimulation of the auricular branch of the vagal nerve 
Study Product Guidelines and Considerations​
63 of 68​Version 3.1 
​
​November 25th, 2024 

(auricular t-VNS): a randomized, monocentric clinical trial. The journal of headache 
and pain 16, 543, doi:10.1186/s10194-015-0543-3 (2015). 
82​
Miyazaki, M., Tanaka, I. & Ezure, K. Excitatory and inhibitory synaptic inputs 
shape the discharge pattern of pump neurons of the nucleus tractus solitarii in the 
rat. Experimental brain research 129, 191-200 (1999). 
83​
Baekey, D. M., Molkov, Y. I., Paton, J. F., Rybak, I. A. & Dick, T. E. Effect of 
baroreceptor stimulation on the respiratory pattern: insights into 
respiratory-sympathetic interactions. Respiratory physiology & neurobiology 174, 
135-145, doi:10.1016/j.resp.2010.09.006 (2010). 
84​
Miyazaki, M., Arata, A., Tanaka, I. & Ezure, K. Activity of rat pump neurons is 
modulated with central respiratory rhythm. Neuroscience letters 249, 61-64 (1998). 
85​
Napadow, V. et al. Evoked pain analgesia in chronic pelvic pain patients using 
respiratory-gated auricular vagal afferent nerve stimulation. Pain Med 13, 777-789, 
doi:10.1111/j.1526-4637.2012.01385.x (2012). 
86​
Zhou, Z., Champagnat, J. & Poon, C. S. Phasic and long-term depression in 
brainstem nucleus tractus solitarius neurons: differing roles of AMPA receptor 
desensitization. J. Neurosci. 17, 5349-5356 (1997). 
87​
Domecq, J. P. et al. Patient engagement in research: a systematic review. BMC 
Health Serv Res 14, 89, doi:10.1186/1472-6963-14-89 (2014). 
88​
Forsythe, L. P. et al. Patient and Stakeholder Engagement in the PCORI Pilot 
Projects: Description and Lessons Learned. J Gen Intern Med 31, 13-21, 
doi:10.1007/s11606-015-3450-z (2016). 
89​
Cherkin, D. C. et al. A randomized trial comparing acupuncture, simulated 
acupuncture, and usual care for chronic low back pain. Arch Intern Med 169, 
858-866, doi:169/9/858 [pii] 
10.1001/archinternmed.2009.65 (2009). 
90​
Britton, W. B. et al. Dismantling Mindfulness-Based Cognitive Therapy: Creation 
and validation of 8-week focused attention and open monitoring interventions 
within a 3-armed randomized controlled trial. Behav Res Ther 101, 92-107, 
doi:10.1016/j.brat.2017.09.010 (2018). 
91​
Lee, J. et al. Reduced insula habituation associated with amplification of trigeminal 
brainstem input in migraine. Cephalalgia : an international journal of headache, 
doi:10.1177/0333102416665223 (2016). 
92​
Kastrup, A., Kruger, G., Neumann-Haefelin, T. & Moseley, M. E. Assessment of 
cerebrovascular reactivity with functional magnetic resonance imaging: comparison 
of CO(2) and breath holding. Magn Reson Imaging 19, 13-20 (2001). 
93​
Cuthbert, B. N., Schupp, H. T., Bradley, M. M., Birbaumer, N. & Lang, P. J. Brain 
potentials in affective picture processing: covariation with autonomic arousal and 
affective report. Biol Psychol 52, 95-111 (2000). 
94​
Bauer, R. M. Physiologic measures of emotion. J Clin Neurophysiol 15, 388-396 
(1998). 
95​
Vartak, A., Fidopiastis, C., Nicholson, D. & Mikhael, W. Estimation of arousal using 
decomposed skin conductance features - biomed 2009. Biomed Sci Instrum 45, 77-82 
(2009). 
96​
D'Hondt, F. et al. Early brain-body impact of emotional arousal. Frontiers in human 
neuroscience 4, 33, doi:10.3389/fnhum.2010.00033 (2010). 
Study Product Guidelines and Considerations​
64 of 68​Version 3.1 
​
​November 25th, 2024 

97​
Amrhein, C., Muhlberger, A., Pauli, P. & Wiedemann, G. Modulation of 
event-related brain potentials during affective picture processing: a complement to 
startle reflex and skin conductance response? Int J Psychophysiol 54, 231-240, 
doi:10.1016/j.ijpsycho.2004.05.009 (2004). 
98​
Frantzidis, C. A. et al. On the classification of emotional biosignals evoked while 
viewing affective pictures: an integrated data-mining-based approach for healthcare 
applications. IEEE Trans Inf Technol Biomed 14, 309-318, 
doi:10.1109/TITB.2009.2038481 (2010). 
99​
(CSEA-NIMH), C. f. t. s. o. e. a. a.     (The Center for Research in Psychophysiology, 
Gainsville, University of Florida, 1995). 
100​
Kodituwakku, S., Lazar, S. W., Indic, P., Brown, E. N. & Barbieri, R. Point process 
time-frequency analysis of respiratory sinus arrhythmia under altered respiration 
dynamics. Conf Proc IEEE Eng Med Biol Soc 2010, 1622-1625, 
doi:10.1109/IEMBS.2010.5626648 (2010). 
101​
DeBeck, L. D., Petersen, S. R., Jones, K. E. & Stickland, M. K. Heart rate variability 
and muscle sympathetic nerve activity response to acute stress: the effect of 
breathing. Am J Physiol Regul Integr Comp Physiol 299, R80-91, 
doi:10.1152/ajpregu.00246.2009 (2010). 
102​
Jauregui-Renaud, K. et al. Repeatability of heart rate variability during simple 
cardiovascular reflex tests on healthy subjects. Arch Med Res 32, 21-26 (2001). 
103​
Novak, V. et al. Influence of respiration on heart rate and blood pressure 
fluctuations. J Appl Physiol (1985) 74, 617-626 (1993). 
104​
Sin, P. Y., Galletly, D. C. & Tzeng, Y. C. Influence of breathing frequency on the 
pattern of respiratory sinus arrhythmia and blood pressure: old questions revisited. 
Am J Physiol Heart Circ Physiol 298, H1588-1599, doi:10.1152/ajpheart.00036.2010 
(2010). 
105​
Freeman, R. Assessment of cardiovascular autonomic function. Clin Neurophysiol 
117, 716-730, doi:10.1016/j.clinph.2005.09.027 (2006). 
106​
Wieling, W., Van Brederode, J. F., De Rijk, L. G., Borst, C. & Dunning, A. J. Reflex 
control of heart rate in normal subjects in relation to age: a data base for cardiac 
vagal neuropathy. Diabetologia 22, 163-166 (1982). 
107​
Ewing, D. J. et al. Autonomic mechanisms in the initial heart rate response to 
standing. J Appl Physiol Respir Environ Exerc Physiol 49, 809-814 (1980). 
108​
Ewing, D. J., Campbell, I. W., Murray, A., Neilson, J. M. & Clarke, B. F. Immediate 
heart-rate response to standing: simple test for autonomic neuropathy in diabetes. 
Br Med J 1, 145-147 (1978). 
109​
Moses, Z. B., Luecken, L. J. & Eason, J. C. Measuring task-related changes in heart 
rate variability. Conf Proc IEEE Eng Med Biol Soc 2007, 644-647, 
doi:10.1109/IEMBS.2007.4352372 (2007). 
110​
Lovallo, W. The cold pressor test and autonomic function: a review and integration. 
Psychophysiology 12, 268-282 (1975). 
111​
Mourot, L., Bouhaddi, M. & Regnard, J. Effects of the cold pressor test on cardiac 
autonomic control in normal subjects. Physiol Res 58, 83-91 (2009). 
112​
Wirch, J. L., Wolfe, L. A., Weissgerber, T. L. & Davies, G. A. Cold pressor test 
protocol to evaluate cardiac autonomic function. Appl Physiol Nutr Metab 31, 
235-243, doi:10.1139/h05-018 (2006). 
Study Product Guidelines and Considerations​
65 of 68​Version 3.1 
​
​November 25th, 2024 

113​
Ducla-Soares, J. L. et al. Wavelet analysis of autonomic outflow of normal subjects 
on head-up tilt, cold pressor test, Valsalva manoeuvre and deep breathing. Exp 
Physiol 92, 677-686, doi:10.1113/expphysiol.2007.038026 (2007). 
114​
Hess, K. L. et al. Aging affects the cardiovascular responses to cold stress in humans. 
J Appl Physiol (1985) 107, 1076-1082, doi:10.1152/japplphysiol.00605.2009 (2009). 
115​
Mezzacappa, E. S., Kelsey, R. M., Katkin, E. S. & Sloan, R. P. Vagal rebound and 
recovery from psychological stress. Psychosom Med 63, 650-657 (2001). 
116​
Kosinski, M. et al. A six-item short-form survey for measuring headache impact: the 
HIT-6. Qual Life Res 12, 963-974 (2003). 
117​
Stewart, W. F., Lipton, R. B., Dowson, A. J. & Sawyer, J. Development and testing of 
the Migraine Disability Assessment (MIDAS) Questionnaire to assess 
headache-related disability. Neurology 56, S20-28 (2001). 
118​
Martin, B. C. et al. Validity and reliability of the migraine-specific quality of life 
questionnaire (MSQ Version 2.1). Headache 40, 204-215 (2000). 
119​
Sullivan, M. J., Bishop, S. R. & Pivik, J. The Pain Catastrophizing Scale: 
Development and Validation. Psychological Assessment 7, 524-532 (1995). 
120​
Cella, D. et al. The Patient-Reported Outcomes Measurement Information System 
(PROMIS) developed and tested its first wave of adult self-reported health outcome 
item banks: 2005-2008. J Clin Epidemiol 63, 1179-1194, 
doi:10.1016/j.jclinepi.2010.04.011 (2010). 
121​
Cohen, S., Kamarck, T. & Mermelstein, R. A global measure of perceived stress. J 
Health Soc Behav 24, 385-396 (1983). 
122​
Baer, R. A. et al. Construct validity of the five facet mindfulness questionnaire in 
meditating and nonmeditating samples. Assessment 15, 329-342, 
doi:10.1177/1073191107313003 (2008). 
123​
Raes, F., Pommier, E., Neff, K. D. & Van Gucht, D. Construction and factorial 
validation of a short form of the Self-Compassion Scale. Clin Psychol Psychother 18, 
250-255, doi:10.1002/cpp.702 (2011). 
124​
Bornemann, B., Herbert, B. M., Mehling, W. E. & Singer, T. Differential changes in 
self-reported aspects of interoceptive awareness through 3 months of contemplative 
training. Frontiers in Psychology 5, 1504, doi:10.3389/fpsyg.2014.01504 (2015). 
125​
Neumann, A., van Lier, P. A., Gratz, K. L. & Koot, H. M. Multidimensional 
assessment of emotion regulation difficulties in adolescents using the Difficulties in 
Emotion Regulation Scale. Assessment 17, 138-149, doi:10.1177/1073191109349579 
(2010). 
126​
French, D. J. et al. Perceived self-efficacy and headache-related disability. Headache 
40, 647-656 (2000). 
127​
Wolfe, F. & Häuser, W. Fibromyalgia diagnosis and diagnostic criteria. Ann Med 43, 
495-502, doi:10.3109/07853890.2011.595734 (2011). 
128​
Perkins, H. E. Measuring love and care for nature. Journal of Environmental 
Psychology 30, 455-463, doi:10.1016/j.jenvp.2010.05.004 (2010). 
129​
Mayer, F. S. & Frantz, C. M. The connectedness to nature scale: A measure of 
individuals’ feeling in community with nature. Journal of Environmental Psychology 
24, 503-515, doi:https://doi.org/10.1016/j.jenvp.2004.10.001 (2004). 
Study Product Guidelines and Considerations​
66 of 68​Version 3.1 
​
​November 25th, 2024 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Appendix 1. Elaboration of Randomization Procedures 
 
The randomization scheme used in the trial is designed to accommodate the complex 
interplay of the logistical considerations of delivering the interventions (e.g., the mindfulness 
intervention is administered in groups), the reality of scheduling scanner time months in 
advance, and best ensuring balance in the groups on baseline headache frequency. To obtain 
proper randomized allocations while accommodating these restrictions, two randomization 
procedures are combined to generate allocations: 
 
Permuted blocks randomization:  
A permuted block randomization strategy will first be used to generate a sequence of 
intervention groups denoted by their temporal order (e.g., the first through Nth intervention 
assignment). The 2 x 2 design yields 4 intervention conditions that are each conducted at 
scheduled times with groups of participants that have been recruited and have established 
eligibility for inclusion (n = 6 to 10 per group). A single block size, 8, will be used to maintain 
the masking of randomization order. Approximately 16 group cohorts will be conducted (i.e., 16 
randomization assignments are expected to be required to fulfill sample size targets). This 
strategy will maintain a strict balance of intervention group assignments after each block of 8 
groups has been conducted (though the participant sample sizes might differ across groups, see 
below). A restriction on the randomization will be imposed such that sequential randomization 
assignments will not be allowed to be identical. In this way, back-to-back group cohorts cannot 
be assigned the same combination of interventions (i.e. RAVANS tVNS and MM). These 
assignments will be conducted using the ‘randomizeR’ package in R. 
 
Covariate adaptive randomization 
Because of the importance of balanced group assignment to this project, an adaptive 
randomization will be conducted to specifically balance all four groups on baseline headache 
frequency.  Headache frequency, or the number of headache days per month, is a variable that is 
itself associated with medication intake, headache-related disability, and affective distress. Thus, 
Study Product Guidelines and Considerations​
67 of 68​Version 3.1 
​
​November 25th, 2024 

balancing all four intervention groups on baseline headache frequency will better ensure balance 
on a host of variables that are likely to impact outcome.  
The study will be conducted by selecting the next two available treatment allocation cohorts 
at each scheduled time. These two cohorts are referred to as ‘yoked cohorts’ because they will be 
conducted nearly simultaneously and because they will share the same pool of eligible 
participants for covariate adaptive randomization. Because of the restrictions in the 
randomization order (above), there will be two separate intervention groups in each yoked cohort 
and this will allow for the degrees of freedom required to perform covariate adaptive 
randomization.  
​
Each participant in the yoked cohort pool will be assigned a sequential number based on 
the temporal order of his or her signed consent (1 to 24). Then, the covariate adaptive 
randomization procedures will be used to allocate sequential participants to one of the two 
interventions based on the assignment that minimizes the imbalance between these two groups 
on baseline headache frequency. This procedure is based on estimating a statistical test (χ2 
goodness-of-fit) and considers all of the participants that have been randomized to these two 
groups up to the current assignment (i.e., cumulatively). The assignment that minimizes the 
imbalance is allocated to that participant and the next participant on the list is then considered 
until all participants have been assigned to one of the two yoked cohorts. This process is repeated 
for each yoked cohort and will produce a balance in baseline headache frequency across all four 
intervention groups. These assignments will be conducted using the ‘SeqAlloc’ package in R. 
   
  
 
Study Product Guidelines and Considerations​
68 of 68​Version 3.1 
​
​November 25th, 2024