A Prospective, Randomized, Vehicle-Controlled, Double-Blind, Phase 2 Study to Assess the Safety, Tolerability, and Efficacy of B244 Delivered as an Intranasal Spray for Preventive Treatment in Subjects With Episodic Migraine
Phase: PHASE2
Conditions: Migraine
Sponsor: AOBiome LLC

CONFIDENTIAL 
 
MGB244-001 Amendment 2 (22Jun2018). AOBiome, LLC 
 
1
 
 
CLINICAL TRIAL PROTOCOL 
Phase II 
 
COMPOUND: 
B244 
 
 
 
 
A Prospective, Randomized, Vehicle-Controlled, Double-Blind, Phase 2 Study to 
Assess the Safety, Tolerability, and Efficacy of B244 Delivered as an Intranasal 
Spray for Preventive Treatment in Subjects with Episodic Migraine 
 
 
STUDY NUMBER: MGB244-001 
 
 
 
VERSION DATE: June 22, 2018 
 
 
 
Sponsor: 
AOBiome LLC 
One Broadway 
14th Floor 
Cambridge, MA 02142-1100 
 
 
 
Any and all information presented in this document shall be treated as confidential and shall remain the 
exclusive property of AOBiome LLC (or any of its affiliated companies). The use of such confidential 
information must be restricted to the recipient for the agreed purpose and must not be disclosed, published 
or otherwise communicated to any unauthorized persons, for any reasons, in any form whatsoever without 
the prior written consent of AOBiome LLC (or the concerned affiliated company)
NCT03488563

CONFIDENTIAL 
 
MGB244-001 Amendment 2 (22Jun2018). AOBiome, LLC 
 
2
 
Revision Chronology 
Original 
January 19, 2018 
Amendment 1 
March 26, 2018 
Amendment 2 
June 22, 2018 
 
 
 

6/26/18

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Statement of Compliance 
 
 
The study will be carried out in accordance with Good Clinical Practice (GCP) as 
required by the following: 
 United States (US) Code of Federal Regulations (CFR) applicable to clinical 
studies (45 CFR Part 46; 21 CFR Part 50, 21 CFR Part 56, and 21 CFR Part 312) 
 ICH E6; 62 Federal Register 25691 (1997) 
 
All key personnel (all individuals responsible for the design and conduct of this study) 
have completed Good Clinical Practice Training. 
 
 
 

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CLINICAL TRIAL SUMMARY 
COMPOUND: B244  
 
 
 
STUDY NUMBER: MGB244-001 
TITLE: 
A Prospective, Randomized, Vehicle-
Controlled, Double-Blind, Phase 2 Study 
to Assess the Safety, Tolerability, and 
Efficacy of B244 Delivered as an 
Intranasal Spray for Preventive Treatment 
in Subjects with Episodic Migraine 
INVESTIGATIONAL PRODUCT 
B244 
STUDY PHASE 
2 
STUDY ARMS 
B244 (140ul per nostril; OD 0.5; 1x109 
cells/ml);  
B244 (140ul per nostril; OD 2.0; 4x109 
cells/ml);  
Vehicle (140ul per nostril); 
PURPOSE: 
To assess the safety, tolerability and 
efficacy of B244 relative to vehicle in 
subjects with episodic migraine.   
OBJECTIVES: 
Primary Objective 
x To assess the safety and 
tolerability of B244 relative to 
vehicle for the preventive 
treatment of episodic migraine.  
Safety and tolerability will be 
assessed by reporting of AEs, 
physical examination, neurological 
examination, and vital signs (blood 
pressure, heart rate, respiratory 
rate). 
 
Secondary Objective(s) 

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x To evaluate the efficacy of B244 
relative to vehicle for migraine 
prevention in subjects with 
episodic migraine. 
x To continue to assess safety during 
the 28 day follow-up period. 
Exploratory Objective  
x To evaluate the effect of B244 on 
changes in cytokine concentration 
in nasal fluid and blood. 
ENDPOINTS: 
Primary 
x 
Safety as assessed by incidence 
and severity of AEs, physical 
examination, neurological 
examination, and vital signs (blood 
pressure, heart rate, respiratory 
rate). 
 
Secondary 
x 
Mean change in monthly migraine 
days from baseline to 12 weeks of 
treatment. 
x 
Proportion of subjects 
experiencing a t50%, t75%, and 
100% reduction in monthly 
migraine days from baseline to 12 
weeks of treatment. 
x 
Mean change in monthly migraine 
attacks from baseline to 12 weeks 
of treatment. 
x 
Mean change in monthly migraine 
days from baseline to the 4-week 
period after first dose of study 
drug.  
x 
Mean change in monthly acute 
migraine specific medication days 
from baseline to 12 weeks of 
treatment. 

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x 
Mean change in monthly moderate 
and severe headache days 
(migraine pain-intensity score) 
from baseline to 12 weeks of 
treatment. 
x 
Mean change in monthly headache 
days from baseline to 12 weeks of 
treatment. 
x 
Mean change in monthly headache 
hours from baseline to 12 weeks of 
treatment. 
x 
Mean change from baseline to 12 
weeks of treatment in disability, as 
measured by the Migraine 
Disability Assessment (MIDAS) 
questionnaire. 
x 
Mean change from baseline to 12 
weeks of treatment in monthly 
Headache Impact Test-6 (HIT-6) 
questionnaire. 
x 
Mean change from baseline to 12 
weeks of treatment in monthly 
Migraine Specific Quality of Life 
questionnaire (MSQL) 
questionnaire. 
x 
Safety assessments after 28 day 
follow-up period. 
x 
Mean change in baseline Clinical 
Global Impression (CGI) score to 
end of treatment period. 
 
Exploratory 
x 
Changes in cytokine concentration 
in nasal fluid and blood from 
baseline to 12 weeks of treatment. 
x 
Mean change in migraine days 
from end of treatment (last month 
of 12 weeks of treatment) to 
follow-up. 

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x 
Mean change in migraine 
associated symptoms: 
nausea/vomiting, photophobia and 
sonophobia from baseline to 12 
weeks of treatment. 
STUDY DESIGN: 
This is a prospective, randomized, 
vehicle-controlled, double-blind, 3-arm 
parallel assignment study assessing the 
safety, tolerability, and efficacy of B244 
delivered as an intranasal spray for 
preventive treatment in subjects with 
episodic migraine. 
This study will enroll 303 subjects.  
Enrolled subjects will undergo a 28 day 
baseline period to establish baseline 
headache frequency and characteristics.  
Subjects will be randomized at the end of 
the baseline period.  Randomization will 
be 1:1:1 so that equal number of subjects 
will be treated in each Arm of the study.   
Subjects will be trained for in-home 
treatment/assessment on the use of the 
nasal spray, and apply their first dose of 
treatment under the supervision of study 
personnel on site. Subjects will remain 
under observation at the study site for 1 
hour post dosing. Subjects will then be 
dispensed study medication for 12 weeks 
of at home dosing (either 1x109 cell/ml; 
4x109 cells/ml; or vehicle). While at 
home, subjects will dose twice daily (am 
and pm) for 12 weeks during the 
prevention treatment phase. Subjects will 
be asked to visit the site every 4 weeks 
during the 12 week treatment period and 4 
week follow-up.   
Daily assessments will be made during the 
12 week double-blind treatment period for 

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safety, tolerability and efficacy.  
Additional safety assessments will be 
made during the follow-up period 28 days 
after last treatment.   Subjects will record 
their dosing, migraine 
incidence/severity/duration, and rescue 
(acute migraine specific) medications 
using a study diary.  
NUMBER OF PATIENTS PLANNED 
FOR RANDOMIZATION: 
Approximately 303 subjects will be 
enrolled in order to achieve a target 
sample size of 264 (i.e., 88 subjects per 
arm), allowing for a 10-15% drop-out 
rate. 
STUDY POPULATION: 
 
Male and female subjects, 18 to 65 years 
of age, with a history of episodic migraine 
are eligible for enrollment.  Subjects must 
be willing to refrain from using any 
treatments that are or might be considered 
useful for migraine prevention including 
recognized pharmaceutical products, 
investigational products, herbal medicines 
or supplements while participating in this 
study. Use of acute treatment is allowed 
throughout the study with the study 
subjects’ usual acute medication of choice 
(usually a triptan, possibly NSAID or 
analgesic) but not intranasal formulations.  
Subjects should not initiate a preventive 
medication during study. 
MAIN INCLUSION/EXCLUSION 
CRITERIA: 
Inclusion Criteria 
1. Males and Females, 18 to 65 years 
of age.  
2. In good general health as 
determined by a thorough medical 
history and physical examination, 
and vital signs.  
3. At least a 1-year history of 
migraine with or without aura that 

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began before the age of 50 years 
old and consistent with a diagnosis 
of migraine with or without aura 
according to the International 
Classification of Headache 
Disorders, 3rd edition, beta 
version. 
4. Experiences 4-14 migraine days 
per month and 3-14 migraine 
attacks per month and no more 
than 14 headache days per month 
(including migraine and non-
migraine headache days) in the 3 
months prior to screening. 
5. Experiences 4-14 migraine 
headache days per month during 
the baseline period.  
6. Ability and willingness to abstain 
from taking medications not 
allowed by the protocol or 
administering any foreign 
substance intranasally. 
7. Ability and willingness to 
complete a migraine-history diary 
from screening to treatment with 
study drug and a migraine-
treatment diary from prevention 
treatment through the remainder of 
the follow-up period.  
 
Exclusion Criteria 
Subjects who meet any of these criteria 
are not eligible for enrollment as study 
participants: 
1. Headache on greater than 14 
days/month in any of the three 
months (90 days) preceding entry 
into the study. 
2. Use of acute migraine-specific 
medications (e.g., ergotamine, 
triptan) on more than 10 days per 

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month in the previous 3 months 
and during study. 
3. Use of intranasal migraine 
medications during study. 
4. Use of any intranasally 
administered over-the-counter 
product or nasal irrigation (e.g., 
neti pot) during study. 
5. Opioids/barbiturates used on more 
than 4 days per month in the 
previous 3 months and throughout 
the duration of the study. 
6. Use of analgesics (including 
acetaminophen, nonsteroidal anti-
inflammatory drugs [NSAIDs], 
acetylsalicylic acid, or 
combination analgesics) for 
migraine and non-migraine 
headaches on more than 14 days 
per month in the previous 3 
months and during study. 
7. Use of migraine prevention 
medication within two months 
prior to study and throughout the 
duration of the study. 
8. Botulinum toxin injection within 3 
months prior to screening or 
during study. 
9. Anti-CGRP monoclonal antibody 
(e.g., erenumab, fremanezumab, 
galcanezumab, and eptinezumab) 
injection or infusion within 4 months 
prior to screening or during study. 
10. Small molecule anti-CGRP 
medications in the 30 days prior to 
the screening visit. 
11. Use of systemic antibiotics during 
study. 
12. Pregnancy or breast-feeding. 
13. Female of childbearing potential 
not using adequate contraceptive 
measures. 

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14. Inability to give informed consent. 
15. History of neurological, 
psychiatric, or any other medical 
condition that in the opinion of the 
investigator may compromise the 
subject’s ability to safely 
participate in the study.  
16. Subjects with any significant 
clinical abnormalities which may 
interfere with study participation. 
17. Prior use of AO+ Mist. 
18. Subjects with immunodeficiencies, 
nasal lesions, nasal polyps, or 
sinus infections. 
19. Subjects who have participated in 
an investigational drug trial in the 
30 days prior to the screening visit. 
20. Inability to maintain at least 80% 
diary compliance during the study 
from baseline to follow-up. 
DOSE REGIMEN: 
After screening and recruitment, 
participants will be randomized to one of 
the following arms of the study: 
B244 (140ul per nostril; OD 0.5; 1x109 
cells/ml) twice-a-day for 12 weeks;  
B244 (140ul per nostril; OD 2.0; 4x109 
cells/ml) twice-a-day for 12 weeks;  
Vehicle (140ul per nostril) twice-a-day for 
12 weeks; 
ASSESSMENT SCHEDULE: 
All subjects will attend a screening visit 
(V1) not more than 14 days prior to V2 
(Day -28).  Subjects with a history of 
migraine as defined in the 
inclusion/exclusion criteria who pass 
screening will return to clinic on Day -28 
(V2) for baseline assessments and sent 
home to record their migraine events and 
AEs over the 28 day baseline period using 
a diary. Subjects will return to clinic on 
Day 0 (V3) to determine continued study 

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eligibility.  Subjects who continue to meet 
all inclusion and exclusion criteria will be 
randomized to receive study treatment. 
Subjects will then be trained for in-home 
treatment/assessment on the use of the 
nasal spray, and apply their first dose of 
treatment under the supervision of study 
personnel while on site (V3).  Subjects 
will remain under observation at the study 
site for 1 hour post dosing. Subjects will 
then be dispensed study medication for 12 
weeks of at home dosing (either 1x109 
cell/ml; 4x109 cells/ml; or vehicle). While 
at home, subjects will dose twice daily 
(am and pm) for 12 weeks during the 
prevention treatment phase, starting with 
the second dose of the first day of 
treatment.  
Subjects will record their dosing, migraine 
events, and rescue medications daily and 
return to clinic every 4 weeks during the 
12 week treatment period at Day 28 (V4), 
Day 56 (V5), and Day 84 (V6) for safety 
and additional prevention treatment 
assessments.  Additional safety 
assessments will be made during the 28 
day follow-up period and end of study 
visit at Day 112 (V7). 
STATISTICAL CONSIDERATIONS: 
Sample Size: Group sample sizes of 88 
per arm achieve 80% power to reject the 
null hypothesis of equal means when the 
SRSXODWLRQPHDQGLIIHUHQFHLV
1 - 2 = -
3.8 - -2.3 = -1.5ZKHUH
1 = -3.8 is the 
mean reduction in migraine headache days 
IRUDQDFWLYHWUHDWPHQWDUPD
2 = -2.3 
is the mean reduction in migraine 
headache days for placebo. The sample 
size calculation assumes a standard 
deviation for both groups of 4.0 and a 
Bonferroni adjusted significance level 

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(alpha) of 0.05 using a one-sided two-
sample equal-variance z-test for the 
comparison of each active treatment arm 
versus vehicle.  
Safety: The analysis of safety will be 
based on the safety population, which is 
defined as all subjects receiving at least 1 
dose of B244 or Vehicle. Adverse events 
(AEs) will be coded using the Medical 
Dictionary for Regulatory Activities 
(MedDRA®) for purposes of 
summarization. All AEs occurring during 
the study will be included in by-subject 
data listings and tabulated. Events leading 
to death, serious AEs, and events resulting 
in study discontinuation will be 
summarized using standard descriptive 
statistics, and presented by treatment arm. 
Exposure to study drug and reasons for 
discontinuation of study treatment will be 
tabulated. Shift tables relative to the 
normal range will be provided for 
laboratory parameters.  Additional 
analyses will be performed, if warranted, 
upon review of the data. 
Efficacy: Efficacy analyses will be 
performed on the intent-to-treat (ITT) 
population, which consists of all 
randomized subjects who receive at least 
1 dose of study medication, and on the per 
protocol (PP) population, which consists 
of subjects who complete their Week 12 
visit and have SHUFHQWFRPSOLDQFH
 50% 
(based on the weight of IP used).  For the 
continuous endpoints of the change in 
migraine days, the change in migraine 
attacks, the change in days using rescue 
medication, the change in headache days, 
the change in headache hours, and the 
change in MIDAS, HIT-6, MSQL, and 
CGI scores, a one-sided two-sample 

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equal-variance z-test will be used to 
compare treatment group means.  Fisher’s 
Exact test will be used to make treatment 
group comparisons on efficacy outcomes 
including the following binary outcomes: 
x Proportion of subjects 
experiencing a t50%, t75%, and 
100% reduction in monthly 
migraine days from baseline to 12 
weeks of treatment. 
Exploratory: Exploratory endpoints will 
be analyzed using the same method as for 
continuous efficacy endpoints. The 
analyses will be performed on the ITT and 
PP population. 
INVESTIGATIONAL DRUG AND 
PLACEBO: 
Investigational drug refers to B244. 
Investigational Product/treatment refers to 
either B244 or Vehicle.  
PLANNED DURATION PER SUBJECT: Up to 22 weeks 
DURATION OF STUDY: 
Estimated study duration (First Subject 
First Visit to Top Line Report) is 9.5 
months.  
 
 
 
 

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1 
STUDY SCHEMA 
 
 
 
Male and Female subjects with a history of migraine 
Screening 
Baseline period (28 days) 
Randomize 
Placebo  
(12 weeks BID)  
B244 1x 
(12 weeks BID)  
B244 4x 
(12 weeks BID)  
Study assessments at 4, 8, 12 weeks 
Prevention Treatment 
Follow up period (28 days) 
End of study  

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Table of Contents 
1 
STUDY SCHEMA ........................................................................................................... 17 
2 
INTRODUCTION ............................................................................................................ 23 
2.1 
Background ..................................................................................................................... 23 
3 
STUDY OBJECTIVES ....................................................................................................... 25 
3.1 
Primary Objectives ........................................................................................................... 25 
3.2 
Secondary Objectives ....................................................................................................... 26 
3.3 
Exploratory Objectives ..................................................................................................... 26 
4 
ENDPOINTS .................................................................................................................. 26 
4.1 
Primary............................................................................................................................ 26 
4.2 
Secondary ........................................................................................................................ 26 
4.3 
Exploratory ...................................................................................................................... 27 
5 
STUDY DESIGN ............................................................................................................. 27 
6 
SELECTION OF STUDY PARTICIPANTS ............................................................................ 27 
6.1 
Number of Participants Planned ....................................................................................... 27 
6.2 
Study Population ............................................................................................................. 28 
6.3 
Inclusion Criteria .............................................................................................................. 28 
6.4 
Exclusion Criteria ............................................................................................................. 28 
7 
PARTICIPANT ENROLLMENT ......................................................................................... 29 
7.1 
Consenting Participants.................................................................................................... 29 
7.2 
Screening for Eligibility ..................................................................................................... 30 
7.3 
Study Withdrawal and Withdrawal From Investigational Product and Stopping Criteria ..... 31 
7.4 
Screen Failures ................................................................................................................. 31 
7.5 
Early Termination ............................................................................................................ 31 
8 
STUDY TREATMENT ...................................................................................................... 32 
8.1 
Investigational Product .................................................................................................... 32 
8.2 
Dose Changes .................................................................................................................. 33 
8.3 
Storage Conditions ........................................................................................................... 33 
8.4 
Description of Blinding Method ........................................................................................ 33 
8.5 
Treatment Assignments: .................................................................................................. 33 
8.6 
Treatment Compliance ..................................................................................................... 34 
8.7 
Treatment Application ..................................................................................................... 34 
8.8 
Treatment of Investigational Product Overdose ................................................................ 35 
8.9 
Product Accountability ..................................................................................................... 35 
8.10 
Unblinding Procedures ..................................................................................................... 35 
8.11 
Retrieval and Destruction of Investigational Product......................................................... 36 
8.12 
Permitted Medications..................................................................................................... 36 
8.13 
Prohibited Medications .................................................................................................... 36 
8.14 
Rescue Medications ......................................................................................................... 37 
8.15 
Handling of Investigational Product .................................................................................. 37 
9 
CONTRACEPTION REQUIREMENTS ................................................................................ 38 

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10 
STUDY PROCEDURES ................................................................................................ 39 
10.1 
Pre-screening Procedures ................................................................................................. 39 
10.2 
Informed Consent Procedures .......................................................................................... 39 
10.3 
Study Assessments ........................................................................................................... 39 
10.4 
Inclusion Procedures ........................................................................................................ 40 
10.5 
Timing of Patient’s Visits to the Clinic ............................................................................... 40 
10.6 
Description by Type of Visit .............................................................................................. 40 
10.6.1 
Screening Visit (V1; Study Day -29) (-42 to -28 days visit window) .................................. 40 
10.6.2 
Baseline (Beginning of 4 Week Baseline Period) (V2; Study Day -28) (-31 to -27 Days Visit 
Window) 41 
10.6.3 
Randomization (End of 4 Week Baseline Period) (V3; Study Day 0) (±3 Days Visit 
Window) 41 
10.6.4 
Prevention Treatment Week 4 (V4; Study Day 28) (±3 Days Visit Window) .................... 42 
10.6.5 
Prevention Treatment Week 8 (V5; Study Day 56) (±3 Days Visit Window) .................... 42 
10.6.6 
Prevention Treatment Week 12 (V6; Study Day 84) (±3 Days Visit Window) .................. 43 
10.6.7 
Follow-Up Week 16 (End of Study) (V7; Study Day 112) (±3 Days Visit Window) ............ 43 
10.6.8 
Unscheduled/Unanticipated or Early Termination Study Visit ......................................... 44 
11 
Methods of Assessments .......................................................................................... 44 
11.1 
Blood Pressure Measurement .......................................................................................... 44 
11.2 
Brief Physical Examinations .............................................................................................. 44 
11.3 
Neurological Examinations ............................................................................................... 45 
11.4 
Blood Collection for Biomarkers ....................................................................................... 45 
11.5 
12-Lead ECG ..................................................................................................................... 45 
11.6 
Nasal Inspection .............................................................................................................. 45 
11.7 
Laboratory Assessments ................................................................................................... 46 
11.8 
Urine Pregnancy Test ....................................................................................................... 46 
11.9 
Nasal Fluid Samples for Biomarkers .................................................................................. 46 
11.10 
Study Diary .................................................................................................................. 47 
11.11 
Migraine Pain Intensity Score ....................................................................................... 49 
11.12 
MIDAS ......................................................................................................................... 49 
11.13 
HIT-6 ........................................................................................................................... 49 
11.14 
MSQL........................................................................................................................... 50 
11.15 
CGI .............................................................................................................................. 50 
11.16 
Sample Shipment ......................................................................................................... 50 
12 
SAFETY ASSESSMENTS .............................................................................................. 50 
12.1 
Compliance ...................................................................................................................... 50 
12.2 
Safety Monitoring ............................................................................................................ 51 
12.3 
Pregnancy Reporting ........................................................................................................ 51 
12.4 
Study Completion ............................................................................................................ 51 
12.5 
Subject Withdrawal Criteria ............................................................................................. 51 
13 
EFFICACY ASSESSMENTS ........................................................................................... 52 
14 
STATISTICAL CONSIDERATIONS ................................................................................. 53 
14.1 
Sample Size...................................................................................................................... 53 
14.2 
Populations for Analysis ................................................................................................... 54 
14.3 
Data Analysis ................................................................................................................... 54 
14.3.1 
Disposition ........................................................................................................................ 54 

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14.3.2 
Demographic and Baseline ............................................................................................... 54 
14.4 
Safety Analyses ................................................................................................................ 55 
14.4.1 
Definitions ......................................................................................................................... 55 
14.4.2 
Adverse Events .................................................................................................................. 55 
14.4.3 
Deaths and Serious Adverse Events .................................................................................. 56 
14.4.4 
Adverse Events Leading to Treatment Discontinuation ................................................... 56 
14.5 
Efficacy Analyses .............................................................................................................. 56 
14.5.1 
Handling of Dropouts or Missing Data .............................................................................. 56 
14.6 
Clinical Trial Protocol Deviations ...................................................................................... 56 
15 
ADVERSE EVENTS (AE) AND SERIOUS ADVERSE EVENTS (SAE) ................................... 57 
15.1 
Definition of an AE ........................................................................................................... 57 
15.2 
Definition of a SAE ........................................................................................................... 57 
15.3 
Time Period, Frequency, and Method of Detecting AEs and SAEs ....................................... 58 
15.4 
Recording of AEs and SAEs ............................................................................................... 58 
15.5 
Evaluating AEs and SAEs ................................................................................................... 59 
15.5.1 
Severity Rating .................................................................................................................. 59 
15.5.2 
Relationship to Investigational product (IP) ..................................................................... 59 
15.6 
Pregnancy ........................................................................................................................ 60 
15.7 
Prompt Reporting of SAEs to the Sponsor ......................................................................... 60 
16 
ETHICAL AND REGULATORY STANDARDS .................................................................. 61 
16.1 
Ethical Conduct of Study .................................................................................................. 61 
16.2 
Laws and Regulations ....................................................................................................... 62 
16.3 
Informed Consent ............................................................................................................ 62 
16.4 
Institutional Review Board/Independent Ethics Committee (IRB/EC) ................................. 62 
16.5 
Clinical Monitoring/Record Keeping ................................................................................. 63 
17 
ADMINISTRATIVE RULES ........................................................................................... 63 
17.1 
Curriculum Vitae .............................................................................................................. 63 
17.2 
Archiving of Study Documentation ................................................................................... 63 
17.3 
Internal Safety Review Committee ................................................................................... 64 
18 
STUDY MONITORING ................................................................................................ 64 
18.1 
Responsibilities of the Investigator(s) ............................................................................... 64 
18.2 
Responsibilities of the Sponsor ......................................................................................... 64 
18.3 
Source Document Requirements ...................................................................................... 65 
18.4 
Use and Completion of Case Report Forms (CRFs) and Additional Requests ....................... 65 
19 
PUBLICATIONS ......................................................................................................... 66 
20 
PROTOCOL ADHERENCE ............................................................................................ 66 
21 
CONFIDENTIALITY ..................................................................................................... 66 
22 
PROPERTY RIGHTS .................................................................................................... 67 
23 
DATA PROTECTION ................................................................................................... 67 
24 
SPONSOR AUDITS AND INSPECTIONS BY REGULATORY AGENCIES ............................. 67 
25 
PREMATURE DISCONTINUATION OF THE STUDY OR PREMATURE CLOSE-OUT OF A SITE
 
68 

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25.1 
Decided by the Sponsor in the Following Cases: ................................................................ 68 
25.2 
Decided by the Investigator .............................................................................................. 68 
26 
CLINICAL TRIAL PROTOCOL AMENDMENTS ............................................................... 68 
27 
APPENDIX A-Schedule of Events ............................................................................... 70 
28 
Appendix B- Migraine Disability Assessment (MIDAS) questionnaire ......................... 75 
29 
Appendix C- Headache Impact Test-6 (HIT-6) questionnaire ...................................... 77 
30 
Appendix D- Migraine Specific Quality of Life (MSQL) questionnaire ......................... 79 
31 
Appendix E- CLINICAL GLOBAL IMPRESSION (CGI) SCALE ........................................... 82 
32 
REFERENCES ............................................................................................................. 84 
 
 
 
 
 
 
 
 
 
 

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LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
AE 
Adverse Event 
AMO 
Ammonia Monooxygenase 
AOB 
Ammonia Oxidizing Bacteria 
BID 
Twice-Daily 
CGI 
Clinical Global Impression 
CRF 
Case Report Form 
eCRF 
Electronic Case Report Form 
EDC 
Electronic Data Capture 
ECG 
Electrocardiogram 
EOS 
End of Study 
E/T 
Early Termination 
FDA 
Food and Drug Administration 
HAO 
NH2OH oxidoreductase 
HIT-6 
Headache Impact Test-6 
ICH 
International Conference on Harmonization 
IEC 
Independent Ethics Committee 
IP 
Investigational Product 
IRB 
Institutional Review Board 
IWRS 
Interactive Web Response System 
MedDRA 
Medical Dictionary for Regulatory Activities 
MIDAS 
Migraine Disability Assessment 
MSQL 
Migraine Specific Quality of Life 
NH2OH 
Hydroxylamine 
NH3 
Ammonia 
NO 
Nitric Oxide 
NO2- 
Nitrite 
PT 
Preferred Term 
SAE 
Serious Adverse Event 
SPM 
Study Procedures Manual 
SOC 
System Organ Class 
TEAE 
Treatment Emergent Adverse Event 
WOCBP 
Women of Child Bearing Potential 
 

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2 
INTRODUCTION 
2.1 
Background 
Migraine is a chronic, recurrent disorder affecting an estimated 37 million Americans.  Migraine 
is marked by recurring moderate to severe headache with throbbing pain that usually lasts from 
4-72 hours, typically unilateral in location, is often accompanied by nausea, vomiting, and 
sensitivity to light or sound, and is sometimes preceded by an aura and is often followed by 
fatigue.  Around 12% of adults have episodic migraine (headaches on less than 15 days per 
month) [3], while around 1% of the adult population suffers from migraine and headaches on 
more days than not [4], a condition termed chronic migraine.  In addition, during a migraine 
attack, individuals experience impaired health-related quality of life and considerable disability 
[5, 6].  
The treatment of migraine consists of acute/abortive therapies and preventive therapies.  The 
acute treatment of migraine includes most commonly, migraine-specific medications such as 
triptans and ergotamines which, while effective in a majority of cases may be limited by side 
effects, the development of medication overuse/rebound and some contraindications including 
cardiovascular, cerebrovascular and peripheral vascular disease and hypertension.  Preventive 
treatments include four medications approved by the FDA for migraine prevention: anti-epilepsy 
medications topiramate and divalproex sodium; and beta-adrenergic blockers propranolol and 
timolol.  These drugs are not disease-specific and are plagued by a plethora of tolerance issues 
including cognitive side effects, weight loss or weight gain, depression, hypotension, etc., and 
therefore adherence to therapy is typically low.   Botulinum Toxin A is approved for the narrow 
indication of chronic migraine prevention but is expensive and requires multiple injections in the 
face, scalp and neck.  In addition, nearly half of individuals with episodic or chronic migraine 
who are in need of preventive therapies do not receive them [7].  
 
Current models for the etiology of migraine headaches support the role of cortical spreading 
depression (CSD) and activation of the trigeminovascular system and its constituent 
neuropeptides, as well as about the importance of neuronal and glial ion channels and 
transporters that contribute to the putative cortical excitatory/inhibitory imbalance that renders 
migraineurs susceptible to an attack [8].  It is our hypothesis that under conditions of stress, 
cortical and trigeminovascular cells have reduced cellular ATP levels as a result of ischemic 
preconditioning.  Intranasal administration of ammonia oxidizing bacteria (AOB) delivers 
physiologic levels of nitric oxide (NO) to these tissues through the oxidation of mucosal 
ammonia.  It has been demonstrated [9] that increases in NO result in corresponding increases in 
cellular ATP levels though a soluble Guanylyl Cyclase (sGC) intermediate.  Increased cellular 
ATP availability supports Na+/K+ ATPase function necessary to maintain membrane electrical 
stability, reducing the risk of excitatory/inhibitory imbalance and subsequent cortical spreading 
depression [10].   
It is believed that intranasal AOB will restore physiologic levels of NO which reduce or reset the 
effects of stress induced ischemic preconditioning and subsequent cortical spreading depression 
associated with migraines. NO is also believed to modulate pain involving nociceptor inhibition 
and central sensitization. Migraine is an inflammatory state as observed by activation of 
macrophages and dendritic cells to an inflammatory state, degranulation of mast cells, and 

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upregulation of pro-inflammatory genes with the initiation of CSD.  To this effect, AOB’s anti-
inflammatory and pain modulatory effects may further improve acute migraine symptoms and 
prevent recurrence of additional migraines.  
 
 
 
 
 
 
 
 
Figure 1 
Nitrifier Denitrification Pathway 
 
AOBs are essential for the initial step in environmental nitrification processes, specifically the 
oxidation of ammonia (NH3) to nitrite (NO2-). Nitrosomonas are Gram-negative 
chemolithoautotrophic betaproteobacteria that obtain energy solely from NH3 oxidation, while 
fixing CO2 for their carbon needs [11]. Oxidation of NH3 proceeds in two steps (Figure 1) 
leading to sequential generation of hydroxylamine (NH2OH) and NO2- that require two enzyme 
complexes: the membrane-bound ammonia monooxygenase (AMO) comprised of subunits 
AmoA, AmoB and AmoC; and the periplasmic NH2OH oxidoreductase (HAO). In addition to 
high NO2- levels, NH3 oxidation leads to nitric oxide (NO) and N2O production through two 
independent pathways downstream of NH2OH production: nitrifier denitrification and NH2OH 
oxidation [12]. 
 
B244 is a purified a strain of Nitrosomonas eutropha, designated D23, originally isolated from 
soil samples. Sequencing of the B244 genome revealed a distinct genetic profile from that of 
other published Nitrosomonas strains and AOB genomes. Based on in vitro co-culture studies, 
B244 was able to reduce survival of pathogenic bacteria. Nitrite generation from ammonia 
concurrently with medium acidification by B244 led to strong antibacterial effects and a marked 
reduction (~100-fold) in viable counts of methicillin-resistant Staphylcoccus aureus and 
Pseudomonas aeruginosa, two pathogens frequently isolated from infected skin and wound sites. 
In contrast, control cultures with B244 in the absence of ammonium or with heat-killed B244 
supplemented with ammonium, had no antibacterial effects. The unique metabolic and 
antimicrobial activity of Nitrosomonas, in combination with their lack of virulence render these 
bacteria as attractive candidates for topical delivery of nitrite and nitric oxide on human skin 
with potential to improve health in both normal and abnormal skin conditions or wound sites. 
NO-releasing drugs or NO donors have also shown activity against Propionibacterium acnes and 
other pathogenic bacteria, anti-inflammatory activity, and inhibition of lipogenesis by insulin-
stimulated immortal sebocytes [13-15].  
To date, there have been no reported infections or health risks associated with topical application 
or ingestion of Nitrosomonas species.  The absence of any illnesses attributed to these bacteria 
despite our widespread exposure indicates that they pose a minimal health risk, if any at all.  
Infection or tissue damage by Nitrosomonas is unlikely, because the sequenced genomes of 
several Nitrosomonas and other AOB lack genes encoding cytotoxins, or other known bacterial 
virulence factors.  Further, AOB are slow growing, as compared to most heterotrophic bacteria, 

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with optimum doubling times of 8 hours or higher.  In particular, Nitrosomonas growth is rate 
limited by the availability of ammonia requiring the oxidation of 27 moles NH3/mole CO2 fixed.  
Due to their dependence on ammonia for their growth, the numbers of Nitrosomonas on the skin 
will be necessarily limited and naturally regulated by the amount of ammonia produced in sweat. 
This would ensure that the amount of nitrite and NO generated would be relatively low, without 
any adverse effects. 
Currently, Nitrosomonas eutropha D23 in buffer at a concentration of 1x109 cells/mL is 
available as a cosmetic product for topical application of a natural source of AOB and NO/NO2 
to improve the appearance of human skin. AOBiome plans to study Nitrosomonas eutropha D23 
diluted in storage solution (50 mM Na2HPO4 and 2 mM MgCl2, pH 7.6) at defined doses to be 
provided as an intranasal spray (B244) for therapeutic applications. 
B244 is being developed under IND #16487 as a ‘live topical’ to provide a natural source of 
AOB and NO/NO2 to the human skin.  Under IND #16487, a phase 1b/2a clinical trial was 
completed in 2016 where 36 participants with clinical diagnosis of facial acne vulgaris were 
randomized to receive ascending doses of investigational product (IP) over 14 days. Safety 
analyses have been completed and there have been no attributable drug related SAEs 
reported.  In addition, a Phase 2b/3 clinical trial in 372 patients with clinical diagnosis of facial 
acne has been completed with a positive safety and efficacy readout with no attributable drug 
related SAEs reported in this trial. 
 
Additionally, other topical development programs with B244 include hypertension (IND 
#17086) and atopic dermatitis (IND #17485).  Under IND #17086, a study titled, “A Prospective, 
Controlled, Double Blinded, Multicenter, Randomized, Vehicle controlled, Phase 
II Study of B244 delivered as a topical spray to Determine Safety and Efficacy in Subjects with 
elevated blood pressure” has been completed.  Under IND #17485, a study titled, “A 
Prospective, Vehicle Controlled, Double Blind, Multicenter, Randomized, Phase II Study of 
B244 Delivered as a Topical Spray to Determine Safety and Efficacy in Subjects with Mild to 
Moderate Atopic Dermatitis” is planned. 
 
Furthermore, B244 is being developed under IND #17085 as a nasal spray for intranasal delivery 
of B244.  A rat toxicology study performed by intranasal administration of B244 twice daily for 
28 days found that B244 was safe and well tolerated in rats at levels of up to the maximum dose 
8x109 cell/mL.  Under IND #17085, a study titled, “A Prospective, Controlled, Double Blinded, 
Single Center, Randomized, 3 arm, Phase 1b/2a Study to Assess the Safety, Tolerability, and 
Preliminary Efficacy of B244 Delivered as an Intranasal Spray in Healthy Volunteers and 
Subjects with Seasonal Allergic Rhinitis” has been initiated. 
 
The proposed clinical study is designed to evaluate the safety, tolerability, and efficacy of 
intranasally delivered B244 for preventive treatment of episodic migraine.  
3 
STUDY OBJECTIVES 
3.1 
Primary Objectives 

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x To assess the safety and tolerability of B244 relative to vehicle for the preventive 
treatment of episodic migraine.  Safety and tolerability will be assessed by reporting of 
AEs, physical examination, neurological examination, and vital signs (blood pressure, 
heart rate, respiratory rate).  
3.2 
Secondary Objectives 
x To evaluate the efficacy of B244 relative to vehicle for migraine prevention in subjects 
with episodic migraine 
x To continue to assess safety during the 28 day follow-up period. 
3.3 
Exploratory Objectives 
x To evaluate the effect of B244 on changes in cytokine concentration in nasal fluid and 
blood. 
4 
ENDPOINTS 
4.1 
Primary 
x Safety as assessed by incidence and severity of AEs, physical examination, neurological 
examination, and vital signs (blood pressure, heart rate, respiratory rate). 
4.2 
Secondary 
x Mean change in monthly migraine days from baseline to 12 weeks of treatment. 
x Proportion of subjects experiencing a t50%, t75%, and 100% reduction in monthly 
migraine days from baseline to 12 weeks of treatment. 
x Mean change in monthly migraine attacks from baseline to 12 weeks of treatment. 
x Mean change in monthly migraine days from baseline to the 4-week period after first 
dose of study drug.  
x Mean change in monthly acute migraine specific medication days from baseline to 12 
weeks of treatment. 
x Mean change in monthly moderate and severe headache days (migraine pain-intensity 
score) from baseline to 12 weeks of treatment. 
x Mean change in monthly headache days from baseline to 12 weeks of treatment. 
x Mean change in monthly headache hours from baseline to 12 weeks of treatment. 
x Mean change from baseline to 12 weeks of treatment in disability, as measured by the 
Migraine Disability Assessment (MIDAS) questionnaire. 
x Mean change from baseline to 12 weeks of treatment in monthly Headache Impact Test-6 
(HIT-6) questionnaire. 

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x Mean change from baseline to 12 weeks of treatment in monthly Migraine Specific 
Quality of Life questionnaire (MSQL) questionnaire. 
x Safety assessments after 28 day follow-up period. 
x Mean change in baseline Clinical Global Impression (CGI) score to end of treatment 
period. 
4.3 
Exploratory 
x Changes in cytokine concentration in nasal fluid and blood from baseline to 12 weeks of 
treatment. 
x Mean change in migraine days from end of treatment (last month of 12 weeks of 
treatment) to follow-up. 
x Mean change in migraine associated symptoms: nausea/vomiting, photophobia and 
sonophobia from baseline to 12 weeks of treatment.  
5 
STUDY DESIGN 
x 
This is a prospective, randomized, vehicle-controlled, double-blind, 3-arm parallel 
assignment study assessing the safety, tolerability, and efficacy of B244 delivered as an 
intranasal spray for preventive treatment in subjects with episodic migraine. 
x 
This study will enroll 303 subjects.  
x 
Enrolled subjects will undergo a 28 day baseline period to establish baseline headache 
frequency and characteristics. 
x 
Subjects will be randomized at the end of the baseline period.  Randomization will be 
1:1:1 so that equal number of subjects will be treated in each Arm of the study. 
x 
Subjects will be trained for in-home treatment/assessment on the use of the nasal spray, 
and apply their first dose of treatment under the supervision of study personnel on site. 
Subjects will remain under observation at the study site for 1 hour post dosing. Subjects 
will then be dispensed study medication for 12 weeks of at home dosing (either 1x109 
cell/ml; 4x109 cells/ml; or vehicle). While at home, subjects will dose twice daily (am 
and pm) for 12 weeks during the prevention treatment phase. Subjects will be asked to 
visit the site every 4 weeks during the 12 week treatment period and 4 week follow-up.  
x 
Daily assessments will be made during the 12 week double-blind treatment period for 
safety, tolerability and efficacy.  Additional safety assessments will be made during the 
follow-up period 28 days after last treatment. Subjects will record their dosing, migraine 
incidence/severity/duration, and rescue (acute migraine specific) medications using a 
study diary. 
6 
SELECTION OF STUDY PARTICIPANTS 
6.1 
Number of Participants Planned 

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Approximately 379 subjects will be consented and screened, allowing for a 20% screen fail rate.  
Approximately 303 subjects will be enrolled in order to achieve a target sample size of 264 (i.e., 
88 subjects per arm), allowing for a 10-15% drop-out rate. 
6.2 
Study Population 
Male and female subjects, 18 to 65 years of age, with a history of episodic migraine are eligible 
for enrollment.  Subjects must be willing to refrain from using any treatments that are or might 
be considered useful for migraine prevention including recognized pharmaceutical products, 
investigational products, herbal medicines or supplements while participating in this study. Use 
of acute treatment is allowed throughout the study with the study subjects’ usual acute 
medication of choice (usually a triptan, possibly NSAID or analgesic), but not intranasal 
formulations.  Subjects should not initiate a preventive medication during study. 
6.3 
Inclusion Criteria 
Deviations from inclusion criteria are not allowed because they can potentially jeopardize 
the scientific integrity of the study, regulatory acceptability or participant safety. Therefore, 
adherence to the criteria as specified in the protocol is essential. 
 
Participants eligible for enrollment in the study must meet all the following criteria: 
1. Males and Females, 18 to 65 years of age.  
2. In good general health as determined by a thorough medical history and physical 
examination, and vital signs. 
3. At least a 1-year history of migraine with or without aura that began before the age of 50 
years old and consistent with a diagnosis of migraine with or without aura according to 
the International Classification of Headache Disorders, 3rd edition, beta version. 
4. Experiences 4-14 migraine days per month and 3-14 migraine attacks per month and no 
more than 14 headache days per month (including migraine and non-migraine headache 
days) in the 3 months prior to screening. 
5. Experiences 4-14 migraine headache days per month during the baseline period. 
6. Ability and willingness to abstain from taking medications not allowed by the protocol or 
administering any foreign substance intranasally. 
7. Ability and willingness to complete a migraine-history diary from screening to treatment 
with study drug and a migraine-treatment diary from prevention treatment through the 
remainder of the follow-up period. 
6.4 
Exclusion Criteria 
Deviations from exclusion criteria are not allowed because they can potentially jeopardize the 
scientific integrity of the study, regulatory acceptability or participant safety. Therefore, 
adherence to the criteria as specified in the protocol is essential. 

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Participants will be excluded from the study if any of the following criteria are met: 
 
1. Headache on greater than 14 days/month in any of the three months (90 days) preceding 
entry into the study. 
2. Use of acute migraine-specific medications (e.g., ergotamine, triptan) on more than 10 
days per month in the previous 3 months and during study. 
3. Use of intranasal migraine medications during study. 
4. Use of any intranasally administered over-the-counter product or nasal irrigation (e.g., 
neti pot) during study. 
5. Opioids/barbiturates used on more than 4 days per month in the previous 3 months and 
throughout the duration of the study. 
6. Use of analgesics (including acetaminophen, nonsteroidal anti-inflammatory drugs 
[NSAIDs], acetylsalicylic acid, or combination analgesics) for migraine or non-migraine 
headaches on more than 14 days per month in the previous 3 months and during study. 
7. Use of migraine prevention medication within two months prior to study and throughout 
the duration of the study. 
8. Botulinum toxin injection within 3 months prior to screening or during study. 
9. Anti-CGRP monoclonal antibody (e.g., erenumab, fremanezumab, galcanezumab, and 
eptinezumab) injection or infusion within 4 months prior to screening or during study. 
10. Small molecule anti-CGRP medications in the 30 days prior to the screening visit. 
11. Use of systemic antibiotics during study. 
12. Pregnancy or breast-feeding. 
13. Female of childbearing potential not using adequate contraceptive measures. 
14. Inability to give informed consent. 
15. History of neurological, psychiatric, or any other medical condition that in the opinion of 
the investigator may compromise the subject’s ability to safely participate in the study.  
16. Subjects with any significant clinical abnormalities which may interfere with study 
participation. 
17. Prior use of AO+ Mist 
18. Subjects with immunodeficiencies, nasal lesions, nasal polyps, or sinus infections. 
19. Subjects who have participated in an investigational drug trial in the 30 days prior to the 
screening visit. 
20. Inability to maintain at least 80% diary compliance during the study from baseline to 
follow-up. 
7 
PARTICIPANT ENROLLMENT 
7.1 
Consenting Participants 
Informed consent for participation in the study must be obtained before performing any study-
specific procedures.  

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Informed Consent Forms for enrolled participants and for participants who are not subsequently 
enrolled will be maintained at the study site in secure study files. Consent will be obtained by 
trained research study staff trained in taking informed consent. The study will be explained with 
the opportunity for the participant to ask questions. If a participant wishes to enter the study, a 
consent form will be completed and signed. 
7.2 
Screening for Eligibility  
Informed consent will be obtained prior to any screening assessments. Screening assessments 
(Visit 1; V1) will be performed within 2 weeks (-14 days) prior to the Baseline visit (V2) and 
will include: medical history and medication use, complete physical examination including 
height, weight, vital signs, and 12-lead ECG, a neurological examination, nasal inspection, 
laboratory testing, including blood sample for a comprehensive metabolic panel, complete blood 
count, chemistry, lipid panel, and liver function test, as well as urinalysis.  Urine pregnancy test 
will be performed on WOCBP.  All screening evaluations must be completed and reviewed to 
confirm that participants meet all eligibility criteria before entering baseline period on Day -28. 
Inclusion and exclusion criteria will be reviewed at Screening (V1), Baseline visit (V2), and 
Randomization visit (V3) to make sure nothing changed.  Enrolled subjects will be asked to 
undergo a 4 week (Day -28 to 0) baseline period.   
 
Eligible subjects will return to clinic on Day -28 (V2) for baseline assessments and will be sent 
home to record their migraine events and acute migraine medication use over the 28 day baseline 
period using a diary. Subjects will return to clinic on Day 0 (V3) for randomization upon 
confirming continued eligibility.  Subjects are randomized at V3 upon confirming the 
inclusion/exclusion criteria and the entry criteria of 4-14 migraine headache days and 80% diary 
compliance during the baseline period. 
 
For subjects who do not meet the 80% daily diary compliance but otherwise meet the 4-14 
migraine days requirement during the baseline period, they can be provided additional 
opportunities to meet the 80% diary compliance requirement to enable continued eligibility for 
randomization.  The following allowances can be made per investigator judgement on a case by 
case basis: 
x If the anticipated diary compliance is slightly less than 80% or short by 4 daily 
diary entries by the day before the randomization visit, subjects can enter up to 4 
additional days of diary entries (over the ±3 day visit window specified in the 
schedule of events in the protocol) as part of the baseline period and reschedule 
the randomization visit immediately after this period.  This provides up to 7 
additional days of diary entries to fulfill compliance. Twenty-eight days prior to 
the new randomization visit day can be re-evaluated for the baseline period.   
x If the anticipated diary compliance is short by more than 4 daily diary entries by 
the day before the randomization visit, the investigator has the option to shift the 
baseline period (i.e., reset) to a randomization visit date that allows subjects to 
record the additional days of diary entries that fulfills 80% compliance and resets 
the baseline period 4 weeks back from the new randomization visit day. 

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x The investigator has the option to request subjects to repeat the baseline period 
(i.e., rebaseline) by entering 28 additional days of diary entries as part of a new 
baseline period and re-evaluate the baseline period 4 weeks back from the new 
randomization visit day. 
 
All screening assessments are listed in the Schedule of Events Table (Appendix A).  A 
participant must meet all inclusion criteria, and none of the exclusion criteria, to be enrolled and 
randomized in this study. The Investigator and team will maintain a screening log to record 
details of all persons screened and to confirm eligibility or record reasons for screening failure, 
as applicable. 
7.3 
Study Withdrawal and Withdrawal From Investigational Product and Stopping 
Criteria  
A participant may withdraw from the study at any time at his/her own request, or may be 
withdrawn at any time at the discretion of the Investigator. 
 
Reasons for withdrawal (participants who refuse to complete any remaining study visits) or 
discontinuation (participants who prematurely stop the application) at any time during the study 
may include, but are not limited, to the following: 
 
 For safety reasons, either at the discretion of the Investigator or at the participant’s 
request 
 For protocol violations at the discretion of AOBiome 
 Due to concomitant therapy that could interfere with the results of the study (the 
Investigator will report all such information on the CRFs and decide, in accordance with 
AOBiome, whether the participant is to be withdrawn).  
 
The reason for participant study withdrawal will be recorded in the electronic Case Report Form 
(eCRF). Data from participants withdrawing from the study will be considered evaluable up to 
the point at which they are withdrawn using the same criteria for evaluability as for participants 
who complete the study. 
7.4 
Screen Failures 
Data for screen and baseline failures will be collected in source documentation at the site 
but will not be transmitted to AOBiome. 
7.5 
Early Termination 
Participants who have discontinued the study early will be evaluated by the Investigator at the 
Early Termination Visit.  See the list of assessments to be performed at the Early Termination 
Visit in the Schedule of Events Table (Appendix A).  Participants with ongoing AEs or SAEs 
believed to be possibly related to investigational product (IP) will continue to be followed until 
resolution or for 30 days as warranted by the nature of the AE.  

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8 
STUDY TREATMENT 
8.1 
Investigational Product 
Under normal conditions of handling and administration, IP is not expected to pose 
significant safety risks to site staff. A Material Safety Data Sheet describing the 
occupational hazards and recommended handling precautions will be provided to site 
staff if required by local laws or will otherwise be available from the Sponsor upon request. 
 
Investigational product must be stored in a secure area under the appropriate physical 
conditions for the product. Access to and administration of the IP will be limited to the 
Investigator and authorized site staff. Investigational product must be dispensed or 
administered only to participants enrolled in the study and in accordance with the protocol. 
 
The Investigator is responsible for study treatment accountability, reconciliation, and record 
maintenance. The Investigator or designated site personnel must maintain study treatment 
accountability records throughout the course of the study. The responsible person(s) will 
document the amount of study treatment received from and returned to the sponsor and the 
amount administered to participants. The required accountability unit for this study will be the 
bottle. Discrepancies are to be reconciled or resolved.  
 
Product name: 
B244, 30ml/bottle 
B244, 30ml/bottle 
Vehicle, 30ml/bottle 
Dosage form: 
B244 suspension 
B244 suspension 
Vehicle solution 
Unit dose strength: 
OD 0.5; 1x109 cells/ml 
OD 2.0; 4x109 cells/ml 
50nM Na2HPO4-2mM 
MgCl2 (pH 7.6) 
Route/administration/duration: 
Intranasal application:  
1 pump per nostril BID 
for 12 weeks 
Intranasal application:  
1 pump per nostril BID 
for 12 weeks 
Intranasal application:  
1 pump per nostril BID 
for 12 weeks 
Dosing instruction: 
Prime the spray with 5 
actuations (pumps) into 
air prior to first use only.  
Apply 1 pump per nostril 
(2 pumps total) in the 
morning and repeat (2 
additional pumps) at 
night for 12 weeks of 
treatment.  Use 1 bottle 
per 4 weeks; 3 bottles per 
kit included. 
Prime the spray with 5 
actuations (pumps) into 
air prior to first use only.  
Apply 1 pump per nostril 
(2 pumps total) in the 
morning and repeat (2 
additional pumps) at 
night for 12 weeks of 
treatment.  Use 1 bottle 
per 4 weeks; 3 bottles per 
kit included. 
Prime the spray with 5 
actuations (pumps) into 
air prior to first use only.  
Apply 1 pump per nostril 
(2 pumps total) in the 
morning and repeat (2 
additional pumps) at 
night for 12 weeks of 
treatment.  Use 1 bottle 
per 4 weeks; 3 bottles per 
kit included. 
Physical description: 
Odorless, cloudy, light 
pink suspension 
Odorless, cloudy, light 
pink suspension 
Odorless, clear, and 
colorless suspension 
Manufacturer/source of 
procurement: 
AOBiome, LLC 
AOBiome, LLC 
AOBiome, LLC 
 

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The contents of the label will be in accordance with all applicable regulatory requirements. B244 
and matching vehicle will be packaged in identical 30 ml white bottles.  
8.2 
Dose Changes 
No dose changes are anticipated. 
8.3 
Storage Conditions  
All investigational drug supplies in the study will be stored in a secure, refrigerated (2-8ºC) safe 
place, under the responsibility of the Investigator or other authorized individual prior to 
randomization and distribution to participants.  All 3 bottles in each kit will be weighed prior to 
distribution to participants and first dosing.  Subjects will be trained for in-home 
treatment/assessment on the use of the nasal spray, have their first dose of treatment on site (V3) 
with the first bottle, and have the bottle reweighed.  Once subjects are sent home with 
investigational product at visit 3 (V3) for preventive treatment, subjects will take out the first 
bottle from the kit and store the investigational product (IP) on the counter (i.e., in room 
temperature 20-25ºC) during use at home or remotely for the first 4 weeks of preventive 
treatment, being mindful to avoid extreme temperatures and areas of excessive heat (e.g., inside 
the car or trunk during heat) or cold (i.e., do not freeze).  The remaining 2 unused bottles in the 
kit will be stored refrigerated (2-8ºC) until use.  A second bottle will be taken out of the 
refrigerator for the second 4 weeks of treatment, and a third bottle will be taken out of the 
refrigerator for the last 4 weeks of treatment.  The new bottles can be used immediately after 
taking them out of the refrigerator for the initial dose or equilibrated in room temperature for 5-
10 minutes prior to use.  Subsequent doses will be administered at room temperature as the IP 
will be left on the counter during the 4 week treatment period.  The used bottles from the 
previous 4 weeks of treatment will be returned at each interim visit (V4, V5, or V6) for IP 
compliance (weight measurements). 
8.4 
Description of Blinding Method 
This study will be double-blinded: neither Investigator(s), nor study participants, nor those 
involved in the conduct of the trial (including sponsor staff) will be aware of the treatment the 
participants are receiving. 
8.5 
Treatment Assignments: 
This is a double-blind study. Participants will be randomly assigned to one of three study 
treatment groups in a 1:1:1 ratio in accordance with the randomization schedule generated for the 
allocation of vehicle or the 2 dose levels of B244 prior to the initiation of the trial. 
Randomization will be centrally-based and performed using an appropriate randomization 
system.  
 
Each participant scheduled to receive investigational product (IP) will receive a randomization 
number at the time of randomization. The randomization number will be used to identify the 
study medication kit assigned to the participant and indicate the treatment to be administered to 
that participant.  

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8.6 
Treatment Compliance 
Study treatment must be dispensed or administered according to procedures described 
herein. Only participants enrolled in the study may receive study treatment. Only authorized site 
personnel may supply study treatment. Participants will record use of the study medication 
utilizing the study diary at the time of use each day. Participants will review study medication 
compliance with the Investigator or designee. Any missed doses, timing, and reason for missed 
dose will be recorded in the eCRF. There should be no doubling of doses to make up for missed 
doses. If a dose is missed, the next dose of study medication should be taken as scheduled. 
 
Each site participating in the trial will be instructed to assess subject’s compliance by weighing 
the investigational product and obtaining the weight of the bottle in grams pre and post 
application during preventive treatment (all 3 unused bottles at visit V3 before the on-site first 
dose, after priming of first bottle at V3, after 4 weeks dosing of first bottle at V4, after 4 weeks 
dosing of second bottle at V5, and after 4 weeks dosing of third bottle at V6).  Weight 
measurements may be performed with the protection cap and safety clip from each bottle 
removed.  Sites will be provided scales, which will be calibrated prior to each use. Study 
personnel will be instructed to record measurements into the eCRF. 
8.7 
Treatment Application 
Subjects will receive one kit containing three 30 ml bottles at the Randomization visit (Visit 3) 
for the 12 week application period, with each bottle assigned for 4 weeks of application.  
Subjects will be instructed in the use of the spray bottle and asked to self-administer the 
Investigational Product as follows: 
x Spray 1 pump of medication into each nostril twice a day for 12 weeks 
 
Instructions for Nasal Spray Administration: 
x 
Shake bottle gently 
x 
Prime nozzle if unused; Pump until mist appears (5 times) 
x 
Place nozzle straight up one nostril and pump once 
x 
Sniff gently after spraying 
x 
Repeat other nostril 
x 
Wipe spray nozzle with tissue when done 
x 
Do not wash/rinse the application site or blow nose for 30 min after applying the mist 
 
Preventive Treatment: 
Subjects will be trained for in-home treatment/assessment on the use of the nasal spray at the end 
of the 4 week baseline period (at visit V3), and apply their first dose of treatment under the 
supervision of study personal while on site.  Subjects will remain under observation at the study 
site for 1 hour post dosing.  Subjects will then be dispensed study medication for 12 weeks of at 
home dosing (kit containing three 30 mL bottles of either dose of 1x109 cells/ml; 4x109 cells/ml 
or vehicle). While at home, subjects will dose twice daily (am and pm; morning and night) for 12 
weeks during the prevention treatment phase, starting with the second dose of the first day of 
treatment.   

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x Treatment application:  1 pump per nostril (2 pumps) BID for 12 weeks; 2 pumps in the 
morning and 2 pumps at night; 4 pumps total per day; 336 total pumps during 12 weeks 
x Subjects may not wash/rinse the application site or blow their nose after applying the IP 
for 30 minutes 
x The spray bottle can be stored at room temperature during use for each 4 week interval.  
A new spray bottle will be taken out of the refrigerator for use during the next 4 weeks. 
After each 4 week use, the used spray bottle will be returned to the site for compliance 
measurement. 
8.8 
Treatment of Investigational Product Overdose 
The sponsor does not recommend specific treatment for an overdose.  
8.9 
Product Accountability 
In accordance with federal and local regulatory requirements, the Investigator and designated site 
personnel must document the amount of investigational product dispensed to study participants, 
the amount returned by study participants, and amount received and returned to the sponsor, 
when applicable. Product accountability records must be maintained throughout the course of the 
trial. Any quality issue noticed with the receipt or use of an IP (deficient IP in condition, 
appearance, pertaining documentation, labeling, expiry date, etc.) should be promptly reported to 
the Sponsor, who will initiate a complaint procedure.  
 
All investigational product must be stored in a secure locked room with access limited to the 
Investigator and designated site personnel. Study product is to be stored in a refrigerator between 
2-8 degrees C. Maintenance of a temperature log is required.  
 
Under no circumstances will the Investigator allow IP to be used other than as directed by this 
Clinical Trial Protocol, or dispose of IP in any other manner.  
8.10 Unblinding Procedures 
The Investigator may unblind a participant’s treatment assignment only in the case of emergency 
or in the event of a serious medical condition when knowledge of the study treatment is essential 
for the appropriate clinical management or welfare of the participant, as determined by the 
Investigator. It is preferred (but not required) that the Investigator first contacts the medical 
monitor to discuss options before unblinding the participant’s treatment assignment. The 
Investigator must notify the Sponsor as soon as possible when a participant’s treatment 
assignment is unblinded without revealing the treatment assignment of the unblinded participant 
unless that information is deemed important for the safety of participants currently in the study. 
The date and reason for the unblinding must be documented in the participant’s study record.  
 
The Medical Monitor may unblind the treatment assignment for any participant with an SAE. If 
the SAE requires that an expedited regulatory report be sent to one or more regulatory agencies, 
a copy of the report, identifying the participant’s treatment assignment, may be sent to clinical 
Investigators in accordance with local regulations and/or sponsor policy. 

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8.11 Retrieval and Destruction of Investigational Product 
All partially used or unused treatments will be returned to the site as brought by study 
participants. A detailed treatment log of the returned IP shall be established.  
The site will not destroy unused IP unless the Sponsor provides written authorization to the 
contrary. All used and unused bottles will be shipped to the authorized drug depot at the end of 
the study.  
8.12 Permitted Medications 
All participants will be screened for concomitant medications prior to inclusion into the study.  
Any concomitant medication to treat adverse events will be recorded in the Concomitant 
Medication section of the eCRF. 
 
8.13 Prohibited Medications 
Subjects must be willing to refrain from using any treatments that are or might be considered useful 
for migraine prevention including recognized pharmaceutical products, investigational products, 
herbal medicines or supplements while participating in this study.  A list of prohibited medications 
includes but is not limited to: 
x Beta blockers:  for example, propranolol, metoprolol, atenolol, bisoprolol, timolol, 
nadolol (Corgard) 
x Calcium channel blockers or antiserotonergic agents:  for example, verapamil, 
flunarizine, pizotifen 
x Antidepressants (TCAs, SNRIs):  for example, amitriptyline, nortriptyline, venlafaxine, 
duloxetine 
x Angiotensin receptor blockers (ARBs) and angiotensin converting enzyme blockers 
(ACEs):  for example, candesartan, lisinopril 
x Onabotulinumtoxin A (Botox) 
x Anticonvulsants:  topiramate (Topamax), valproic acid (Depakote), divalproex sodium 
(Depakote), and gabapentin (These are the only ones not permitted; others are allowed if 
required for treatment of a seizure disorder. If a subject must use any of these prohibited 
drugs, the subject will not be eligible for the study.) 
x Triptans and ergots if used as preventive/pre-emptive medications (These are allowed for 
acute treatment of migraine, as described and limited below in section 8.14.) 
x NSAIDs used as preventive medications (daily basis for migraine or other indications) 
(These are allowed for acute treatment of migraine, as described and limited below in 
section 8.14.) 
x Devices for migraine prevention 
x Nerve blocks in the head and neck 
x Anti-CGRP monoclonal antibody (for example, erenumab, fremanezumab, 
galcanezumab, and eptinezumab) injection or infusion 
x Small molecule anti-CGRP medications 

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x Systemic antibiotics (oral or IV only) 
x Intranasal formulations of acute/abortive rescue medications such as sumatriptan 
(Imitrex, Onzetra) and zolmitriptan (Zomig).  All triptans are allowable for acute 
treatment of migraine as described and limited to below including Relpax (eletriptan), 
Maxalt (rizatriptan), Amerge (naratriptan), Imitrex (sumatriptan), Axert (almotriptan), 
Frova (frovatriptan) and Zomig (zolmitriptan) 
x Any herbal medicines or supplements related to migraine prevention such as vitamin B2 
(riboflavin), butterbur, feverfew, high dose magnesium, etc. 
If needed, subjects are allowed to use their usual migraine specific medication of their choice to 
relieve their symptoms of an acute attack of migraine, although they must avoid medications that 
are sprayed into their nose.  Subjects are prohibited from using any migraine-specific 
medications as preventive treatment between acute episodes. A list of medications that are 
allowed includes: 
x All acute/abortive migraine medications (via mouth or injection only) such as triptans and 
ergot containing preparations (ergotamine tartrate, DHE 45) up to 10 days per month 
x NSAIDs and analgesics (for example, acetaminophen, acetylsalicylic acid, combination 
analgesics) for migraine and non-migraine headaches up to 14 days per month 
x Opioid/barbiturate containing medications of up to 4 days per month 
8.14 Rescue Medications 
Use of rescue medication is allowed throughout the study with subjects’ usual acute migraine 
specific medication of choice to relieve their symptoms of an acute attack of migraine (usually a 
triptan, possibly NSAID or analgesic) and recorded in the eCRF.  Subjects should avoid intranasal 
formulations of rescue medications.  Subjects should not initiate a preventive medication during 
study and are prohibited from using any migraine-specific medications as preventive treatment 
between acute episodes.  Subject may not start additional non-randomized medication and should 
immediately alert the study site PI.  Subjects are encouraged not to start any new acute 
migraine/headache treatments during the course of the study and may be withdrawn from the study 
pending discussion with the PI and sponsor medical monitor in such cases.  If discontinuation is 
necessary, this would be considered an early termination.  A list of allowed rescue medications 
includes: 
x 
All acute/abortive medications (excluding intranasal formulations) such as triptans (oral 
or injection route only) and ergot containing preparations (ergotamine tartrate, DHE 45 
by IM, SQ, IV) up to 10 days per month 
x NSAIDs and analgesics (e.g., acetaminophen, acetylsalicylic acid, combination 
analgesics) for migraine and non-migraine headaches up to 14 days per month 
x Opioid/barbiturate containing medications of up to 4 days per month 
 
8.15 Handling of Investigational Product 
Subjects will receive a kit containing three 30 ml white bottles for the duration of the 12 weeks 
of preventive treatment.  Each bottle will be used for 4 weeks for the preventive treatment phase, 

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and brought to all study appointments (V4, V5, V6, Unanticipated/Early Termination visit).  
Subjects will be asked to refrigerate bottles that are not in active use. The bottle which is being 
used for preventive treatment may be placed on the counter at room temperature to be used 
during its 4 week preventive treatment period. The remaining 2 unused bottles in the kit will be 
stored refrigerated (2-8ºC) until use.  A second bottle will be taken out of the refrigerator for the 
second 4 weeks of treatment, and a third bottle will be taken out of the refrigerator for the last 4 
weeks of treatment.  The used bottles from the previous 4 weeks of treatment will be returned at 
each interim visit (V4, V5, or V6) for IP compliance (weight measurements). 
 
Subjects will be asked not to expose the treatment kit to conditions which are unnatural or 
harmful to the product, such as excessive heat (temperatures over 77°F (25°C) and freezing 
temperatures (at 0oC)). Subjects may travel with their study medication but should not leave it in 
the hot car, outside in the cold temperatures etc.  Preferably, subjects will be asked to place the 
IP on the counter at room temperature at home for morning and nighttime dosing.  Subjects will 
also be asked not to tamper or cause damage to IP. 
9 
CONTRACEPTION REQUIREMENTS 
Effective contraception is required for all women physiologically capable of becoming pregnant 
during study participation. Women of child-bearing potential must agree to use an acceptable 
form of contraception for up to 2 weeks after the study completion. Women of childbearing 
potential are defined as any female who has experienced menarche and who is NOT permanently 
sterile or postmenopausal. Postmenopausal is defined as 12 consecutive months with no menses 
without an alternative medical cause. 
 
Effective contraception methods include:  
x Total abstinence (when this is in line with the preferred and usual lifestyle of the 
study participant). Periodic abstinence (i.e., calendar, ovulation, symptothermal, 
postovulation methods) and withdrawal are not acceptable methods of contraception.  
x Use of oral, injected or implanted hormonal methods of contraception or placement of 
an IUD or IUS or other forms of hormonal contraception that have comparable 
efficacy, for example hormone vaginal ring or transdermal hormone contraception.  
x Use of barrier methods (i.e., condom, diaphragm) used with a spermicide (i.e., foam, 
cream, or gel that kills sperm) 
 
In case of use of oral contraception women should have been stable on the same pill for a 
minimum of 90 days before the baseline visit.   
 
Male participants of the study who are having sexual intercourse with a woman who can become 
pregnant must use an acceptable form of birth control if not permanently sterile (e.g., from 
vasectomy) while participating in the study. Additionally, male participants are expected to let 
their female partners know of their participation in a research study of a drug, and that the effects 
of the drug on an unborn baby and on a pregnant woman are unknown. Male participants will 
also be expected to provide their female partners with the contraception requirements 
information previously described and the study doctor’s contact information for questions.  
 

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Payment for all aspects of obstetrical care, child-or related care will be the study participant’s 
responsibility.  
 
In case of pregnancy, Investigational Product should be discontinued and the Sponsor should be 
informed immediately. Follow-up of the pregnancy will be mandatory until the outcome is 
available. 
10 STUDY PROCEDURES 
10.1 Pre-screening Procedures  
Study subjects will be recruited from among participating hospitals, clinics, and diagnostic 
centers, under the responsibility of a participating Investigator. Prior to initiation of the 
recruitment phase, participating Investigators will identify a pool of potential study subjects. 
Each of these centers will identify potentially eligible patients in advance, by either reviewing 
past medical records and diagnoses, screening in clinics, referral from other physicians, or other 
sources of recruitment, including online advertising and patient databases, to identify those aged 
18 to 65 with clinical diagnosis of migraine meeting the inclusion criteria. 
 
10.2 Informed Consent Procedures 
Eligible participants may only be included in the study after providing a consent using the IRB-
approved informed consent. Written informed consent must be obtained before conducting any 
study-specific procedures (i.e. all of the procedures described in the protocol). The process of 
obtaining informed consent should be documented in the participant’s source documents. The 
date of signing of informed consent (and withdrawal, if later withdrawn) should be documented 
in the eCRF. 
10.3 Study Assessments 
Study activities will take place according to the Schedule of Events table (Appendix A). 
 
All subjects will attend a screening visit (V1) not more than 14 days prior to V2 (Day -28).  
Subjects with a history of migraine as defined in the inclusion/exclusion criteria who pass 
screening will return to clinic on Day -28 (V2) for baseline assessments and sent home to record 
their migraine events and rescue (acute migraine treatment) medications over the 28 day baseline 
period using a diary. Subjects will return to clinic on Day 0 (V3) to determine continued study 
eligibility.  Subjects who continue to meet all inclusion and exclusion criteria will be randomized 
to receive study treatment.   
 
Subjects will then be trained for in-home treatment/assessment on the use of the nasal spray, and 
apply their first dose of treatment under the supervision of study personnel while on site (V3).  
Subjects will remain onsite for 1 hour post dosing for observation. Subjects will then be 
dispensed study medication for 12 weeks of at home dosing (either 1x109 cell/ml; 4x109 cells/ml; 
or vehicle). While at home, subjects will dose twice daily (am and pm) for 12 weeks during the 
prevention treatment phase, starting with the second dose of the first day of treatment. 

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Subjects will record their dosing, migraine events, and rescue medications daily and return to 
clinic every 4 weeks during the 12 week treatment period at Day 28 (V4), Day 56 (V5), and Day 
84 (V6) for safety and additional prevention treatment assessments.  Additional safety 
assessments will be made during the 28 day follow-up period and end of study visit at Day 112 
(V7). 
 
At the final visit (V7) or at the Early Termination visit due to study discontinuation or 
withdrawal, subjects may be requested to complete an optional, brief subject satisfaction survey. 
10.4 Inclusion Procedures  
Once all inclusion/exclusion criteria are fulfilled after the 28 day baseline period, the patient 
becomes eligible for randomization and inclusion into the treatment period. Treatment allocation 
will be performed as stated above in Section 8.5. Study medication will be delivered as stated in 
Section 8.7. Patients will be counseled on product application and diary completion.  
10.5 Timing of Patient’s Visits to the Clinic 
Patients will be asked to report to the clinic for their scheduled appointments. If a subject is 
unable to schedule an appointment within the required time frame, study staff will be asked to 
reschedule the patient to a day when they are able to come in within a predetermined time frame.  
10.6 Description by Type of Visit 
10.6.1 Screening Visit (V1; Study Day -29) (-42 to -28 days visit window) 
x 
informed consent completed and signed  
x 
inclusion and exclusion criteria  
x 
demographic data  
x 
medical/surgical history 
x 
smoking status  
x 
record concomitant medications  
x 
obtain in clinic blood pressure, heart rate, respiratory rate 
x 
brief physical exam 
x 
neurological exam 
x 
body weight 
x 
height measurement  
x 
12-lead ECG 
x 
nasal inspection 
x 
laboratory testing (blood for metabolic panel, hematology, clinical chemistry, lipid panel, 
liver function test, urinalysis) 
x 
urine pregnancy test (for women of childbearing potential) 
x 
study AEs 
x 
study diary 
x 
migraine pain intensity score 

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10.6.2 Baseline (Beginning of 4 Week Baseline Period) (V2; Study Day -28) (-31 to -27 
Days Visit Window) 
x 
inclusion and exclusion criteria  
x 
record concomitant medications  
x 
obtain in clinic blood pressure, heart rate, respiratory rate 
x 
brief physical exam 
x 
neurological exam 
x 
body weight 
x 
nasal inspection 
x 
study AEs 
x 
study diary 
x 
migraine pain intensity score 
x 
MIDAS 
x 
HIT-6 
x 
MSQL 
x 
CGI 
10.6.3 Randomization (End of 4 Week Baseline Period) (V3; Study Day 0) (±3 Days 
Visit Window) 
x 
inclusion and exclusion criteria, including entry criteria of 4-14 migraine headache days 
during the baseline period  
x 
record concomitant medications  
x 
obtain in clinic blood pressure, heart rate, respiratory rate 
x 
brief physical exam 
x 
neurological exam 
x 
body weight 
x 
blood collection for biomarkers 
x 
12-lead ECG 
x 
allocation of a randomized treatment kit number via randomization system 
x 
nasal inspection 
x 
delivery of the corresponding pack of Investigational Product 
x 
Investigational Product application  
x 
obtain study medication weight for Investigational Product compliance 
x 
study counseling 
x 
laboratory testing (blood for metabolic panel, hematology, clinical chemistry, lipid panel, 
liver function test, urinalysis) 
x 
nasal fluid collection for biomarkers 
x 
study AEs 
x 
study diary 
x 
migraine pain intensity score 
x 
MIDAS 

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x 
HIT-6 
x 
MSQL 
x 
CGI 
10.6.4 Prevention Treatment Week 4 (V4; Study Day 28) (±3 Days Visit Window) 
x 
record concomitant medications  
x 
obtain in clinic blood pressure, heart rate, respiratory rate 
x 
brief physical exam 
x 
neurological exam 
x 
body weight 
x 
blood collection for biomarkers 
x 
nasal inspection 
x 
Investigational Product application  
x 
obtain study medication weight for Investigational Product compliance 
x 
study counseling 
x 
nasal fluid collection for biomarkers 
x 
study AEs 
x 
study diary 
x 
migraine pain intensity score 
x 
HIT-6 
x 
MSQL 
x 
CGI 
10.6.5 Prevention Treatment Week 8 (V5; Study Day 56) (±3 Days Visit Window) 
x 
record concomitant medications  
x 
obtain in clinic blood pressure, heart rate, respiratory rate 
x 
brief physical exam 
x 
neurological exam 
x 
body weight 
x 
blood collection for biomarkers 
x 
nasal inspection 
x 
Investigational Product application  
x 
obtain study medication weight for Investigational Product compliance 
x 
study counseling 
x 
nasal fluid collection for biomarkers 
x 
study AEs 
x 
study diary 
x 
migraine pain intensity score 
x 
HIT-6 
x 
MSQL 
x 
CGI 

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10.6.6 Prevention Treatment Week 12 (V6; Study Day 84) (±3 Days Visit Window) 
x 
record concomitant medications  
x 
obtain in clinic blood pressure, heart rate, respiratory rate 
x 
brief physical exam 
x 
neurological exam 
x 
body weight 
x 
blood collection for biomarkers 
x 
12-lead ECG 
x 
nasal inspection 
x 
Investigational Product application  
x 
obtain study medication weight for Investigational Product compliance 
x 
laboratory testing (blood for metabolic panel, hematology, clinical chemistry, lipid panel, 
liver function test, urinalysis) 
x 
nasal fluid collection for biomarkers 
x 
study AEs 
x 
study diary 
x 
migraine pain intensity score 
x 
MIDAS 
x 
HIT-6 
x 
MSQL 
x 
CGI 
10.6.7 Follow-Up Week 16 (End of Study) (V7; Study Day 112) (±3 Days Visit Window) 
Every attempt should be made to complete all visits during the defined window periods. 
Subjects who do not complete all required study visits and withdraw from the study will be 
asked to complete an End of Study Evaluation. 
 
x 
record concomitant medications  
x 
obtain in clinic blood pressure, heart rate, respiratory rate 
x 
brief physical exam 
x 
neurological exam 
x 
body weight 
x 
blood collection for biomarkers 
x 
nasal inspection 
x 
nasal fluid collection for biomarkers 
x 
study AEs 
x 
study diary 
x 
migraine pain intensity score 
x 
HIT-6 
x 
MSQL 
x 
CGI 
x 
subject satisfaction survey 

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10.6.8 Unscheduled/Unanticipated or Early Termination Study Visit 
If an event arises that requires patient to come in to the research center, subjects should be 
scheduled for the Unscheduled visit.   
  
During the visit, the following will be obtained:  
x 
record concomitant medications  
x 
obtain in clinic blood pressure, heart rate, respiratory rate 
x 
brief physical exam 
x 
neurological exam 
x 
body weight 
x 
blood collection for biomarkers 
x 
nasal inspection 
x 
obtain study medication weight for Investigational Product compliance 
x 
study counseling 
x 
laboratory testing (blood for metabolic panel, hematology, clinical chemistry, lipid panel, 
liver function test, urinalysis) 
x 
nasal fluid collection for biomarkers 
x 
study AEs 
x 
study diary 
x 
migraine pain intensity score 
x 
MIDAS 
x 
HIT-6 
x 
MSQL 
x 
CGI 
11 METHODS OF ASSESSMENTS 
11.1 Blood Pressure Measurement 
Blood pressure readings will be obtained at every visit as described in Appendix A (schedule of 
events) preferably during standardized times across sites (e.g., mornings). Subject should be 
asked to remove all clothing that covers the location of cuff placement. The individual should be 
comfortably seated in the chair, with the legs uncrossed, and the back and arm supported, such 
that the middle of the cuff on the upper arm is at the level of the right atrium (the mid-point of 
the sternum). Neither the patient nor the observer should talk during the measurement. After 5 
minutes sitting, serial clinic BP measurements and heart (x3) rate will be performed, using the 
non-dominant arm with a calibrated electronic sphygmomanometer. The average of the second 
and third readings will be documented. Respiratory rate (number of breaths per minute) will also 
be recorded. 
11.2 Brief Physical Examinations  
Brief physical examination will be performed at Screening (V1), Baseline (beginning of 4 week 
baseline period; V2), Randomization (end of 4 week baseline period; V3), Prevention Treatment 

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Week 4 (V4), Prevention Treatment Week 8 (V5), Prevention Treatment Week 12 (V6), Follow-
Up Week 16 (End of Study; V7), and at Unanticipated/Early Termination Visit should one occur. 
The physical examination includes an assessment of general appearance and a review of systems 
(dermatologic, head, eyes, ears, nose, mouth/throat/neck, thyroid, lymph nodes, respiratory, 
cardiovascular, gastrointestinal, extremities, musculoskeletal, neurologic systems).  
11.3 Neurological Examinations  
As part of the physical examination at each visit, a neurological examination will be performed 
for assessment of sensory neuron and motor responses, especially reflexes, to determine whether 
the nervous system is impaired. 
11.4 Blood Collection for Biomarkers 
In addition to the blood drawn for the safety laboratory assessments, additional whole blood will 
be collected for the biomarker analysis at Randomization (end of 4 week baseline period; V3), 
Prevention Treatment Week 4 (V4), Prevention Treatment Week 8 (V5), Prevention Treatment 
Week 12 (V6), and Follow-Up Week 16 (End of Study; V7) according to Appendix A.  Samples 
will also be collected in the event of an Unanticipated/Early Termination Visit. 
 
Approximately 15 ml of whole blood will be drawn for biomarkers at each visit. Patients will be 
asked to fast for at least 8 hrs before blood for biomarkers is drawn. 
 
Samples will be processed to serum and plasma on site and stored at -80 |C until shipment to a 
designated central lab for biostorage and may be evaluated for select biomarkers that may 
include several of the following as well as others: 
 
1. Inflammatory cytokines/chemokines/immune cell markers/neuropeptides: IL-1beta, IL-2, 
IL-4, IL-5, IL-6, IL-8, IL-9, IL-10, IL-12p40, IL-12p70, IL-13, IL-15, IL-16, IL-17, IL-
18, TNF-alpha, GM-CSF, MIP-1 alpha, MIP-1 beta, MCP-1, Eotaxin-1, MDC, PGD2, 
beta-tryptase, histamine, C3a/C4a/C5a, LTC4, MMP9, CGRP 
11.5 12-Lead ECG  
12-lead ECG will be taken at Screening (V1), Randomization (end of 4 week baseline period; 
V3), and Prevention Treatment Week 12 (V6).  Standard 12-lead ECGs will be performed 
according to the site SOPs. ECGs should be performed after the subject has been resting supine 
for t 5 minutes. The ECG will include all 12 standard leads and a Lead II rhythm strip on the 
bottom of the tracing. The ECG will be recorded at a paper speed of 25 mm/sec. The following 
ECG parameters will be collected: PR interval, QRS interval, QT interval, and QTc interval 
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presence of abnormalities. 
11.6 Nasal Inspection  
Nasal inspection will include clinical examination of the nasal mucosa, sinuses, and upper 
airway using an otoscope.  Nasal inspection will be performed at the following visits: Screening 

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(V1), Baseline (beginning of 4 week baseline period; V2), Randomization (end of 4 week 
baseline period; V3), Prevention Treatment Week 4 (V4), Prevention Treatment Week 8 (V5), 
Prevention Treatment Week 12 (V6), Follow-Up Week 16 (End of Study; V7), and at 
Unanticipated/Early Termination Visit should one occur. 
11.7 Laboratory Assessments 
Blood sample will be taken for hematology and clinical chemistry, including standard metabolic 
panel, complete blood count (CBC), clinical chemistry, lipid panel, and liver function test.  
Approximately 15 ml of whole blood will be drawn.  Urinalysis will be performed as part of 
safety labs.  Laboratory assessments will be made at Screening (V1), Randomization (end of 4 
week baseline period; V3), Prevention Treatment Week 12 (V6), and at Unanticipated/Early 
Termination Visit should one occur. 
 
Blood samples should be taken using standard venipuncture techniques. Blood sampling will be 
performed according to the site SOPs. 
 
The following laboratory variables will be determined:  Fasting glucose, Uric acid, BUN (blood 
urea nitrogen), Creatinine, BUN/creatinine ratio, eGFR (estimated glomerular filtration rate), 
Sodium, Potassium, Chloride, Calcium, Total protein, Bicarbonate, Albumin, Bilirubin, Alkaline 
phosphatase, AST (aspartate aminotransferase), ALT (alanine transaminase), total cholesterol, 
HDL, LDL, triglycerides, CBC (standard panel including RBC, hemoglobin, hematocrit, 
platelets, and WBC, including neutrophils, lymphocytes, monocytes, eosinophils, basophils), and 
proteinurea.  
 
Any value outside the normal range (except those affected by not fasting) will be flagged for the 
attention of the Investigator or designee at the site. The Investigator or designee will indicate 
whether or not the value is of clinical significance. If the result of the clinical chemistry test from 
the samples taken during the screening phase is indicated as clinically significant, the study 
subject will NOT be allowed into the study.  
11.8 Urine Pregnancy Test  
Standard urine pregnancy testing will be performed on WOCBP as part of screening. 
11.9 Nasal Fluid Samples for Biomarkers 
Nasosorption with synthetic absorptive matrices (SAM) have been used to sample nasal mucosal 
lining fluid [16].  This technique can be considered as “precision mucosal sampling”, since it 
samples directly from the respiratory mucosa, and is free from the salivary contamination that 
occurs in breath and sputum sampling. Nasosorption sampling involves manipulating the 
synthetic absorptive matrix (SAM) up the lumen of the nasal cavity, and then holding it in 
position against the mucosa by external firm finger pressure. This is more comfortable and less 
invasive than using a conventional swab, where rotation against the mucosal surface is generally 
required.  
Nasosorption will be performed by placing strips of a hydrophilic polyester absorptive matrix 

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(Mucosal Diagnostics, Hunt Developments Ltd., Midhurst, UK: available as a CE-marked 
device) measuring 7 × 35 mm into each nostril for 1 min. When the SAM strip is removed, it 
may be placed back in to its container and frozen at í80°C until shipment to a designated central 
lab for biostorage, elution, and testing.  After shipment to a designated lab, SAM strips will be 
washed in 3%6EXIIHUS+OFRQWDLQLQJ%6$DQG7ULWR
cup of a spin filter insert (Costar® Spin-X®). Mucosal lining fluid will be then eluted from the 
SAM by spin filter centrifugation (5 min at 16,000G at 4 °C), left and right nostril samples 
combined, and aliquots tested for biomarkers to evaluate the immune response. 
Nasal fluid for biomarkers will be collected at Randomization (end of 4 week baseline period; 
V3), Prevention Treatment Week 4 (V4), Prevention Treatment Week 8 (V5), Prevention 
Treatment Week 12 (V6), and Follow-Up Week 16 (End of Study; V7) according to Appendix 
A.  Samples will also be collected in the event of an Unanticipated/Early Termination Visit. 
 
Samples may be evaluated for select biomarkers that may include several of the following as 
well as others: 
 
1. Inflammatory cytokines/chemokines/immune cell markers/neuropeptides: IL-1beta, IL-2, 
IL-4, IL-5, IL-6, IL-8, IL-9, IL-10, IL-12p40, IL-12p70, IL-13, IL-15, IL-16, IL-17, IL-
18, TNF-alpha, GM-CSF, MIP-1 alpha, MIP-1 beta, MCP-1, Eotaxin-1, MDC, PGD2, 
beta-tryptase, histamine, C3a/C4a/C5a, LTC4, MMP9, CGRP 
Optionally, samples may be evaluated for nasal microbiome (e.g., PCR) to confirm presence of 
B244. 
11.10 Study Diary 
Subjects will be asked to fill out a daily migraine-history diary from screening to treatment with 
study drug and a migraine-treatment diary from treatment through the remainder of the follow-up 
period.  Study diary will be electronic using an electronic patient reported outcomes (ePRO) 
device. 
 
Study diary entries will be daily and will include recording of migraine frequency, duration, and 
severity that includes information on migraine days (experiencing migraine with or without aura 
in a given day), headache days (experiencing headache in a given day), migraine intensity, 
migraine duration, headache intensity, and headache duration.  Additional patient reported 
outcomes may include recording of nausea, vomiting, photophobia, and sonophobia, as well as   
information about the headache in the trial (i.e., headache intensity, presence/absence of 
associated symptoms, unilateral/bilateral location, aggravation by exercise, throbbing/non-
throbbing) to verify migraine headache symptoms. Subjects will also record their use of rescue 
(acute migraine specific) medications and dosing administration.  The diary will ask the subjects 
about their headache which will allow the patients’ responses to determine whether that 
headache is migraine or not.   
 
The following definitions will be used for determination of migraine, migraine days, and other 
inclusion/exclusion criteria: 
 

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Episodic migraine: 
x 
No more than 14 headache days per month and for this study at least 4 of those days must 
be migraine days. 
Migraine without aura (per International Headache Society [IHS] 1.1 criteria):  
x Headache attacks lasting 4-72 hours 
x At least 2 of the following:  
o unilateral location 
o pulsating quality 
o moderate or severe pain intensity 
o aggravation by or causing avoidance of routine physical activity 
x At least one of the following 
o nausea and/or vomiting 
o photophobia and sonophobia 
 
Migraine with aura (IHS 1.2): 
x 
Migraine associated with one or more of the following fully reversible aura symptoms: 
visual, sensory, speech and/or language, motor, brainstem, retinal. 
x 
At least 3 of the following: 
o At least one aura symptoms spreads gradually over >5 min 
o 2 or more aura symptoms occur in succession 
o Each individual aura symptoms lasts 5-60 min 
o At least one aura symptom is unilateral 
o At least one aura symptom in positive 
o The aura is accompanied or followed within 60 min by HA 
 
Migraine day: 
x 
Migraine day is defined as any calendar day in which the subject experiences a qualified 
migraine headache (onset, continuation, or recurrence of the migraine headache).  It is a 
self-reported headache which meets the IHS criteria for migraine with or without aura or 
probable migraine. A probable migraine is defined as a headache that meets only 2 of the 
3 criteria (listed in the migraine without aura definition). 
x 
If the patient uses a migraine specific medication such as a triptan, that will be counted as 
a migraine day no matter how short the headache attack is as long as it’s at least 30 
minutes. 
x 
Migraine day will be determined from a 24 hour period from 12 am to 11:59 pm each 
day. 
Headache day: 
x 
A non-migraine headache day. 
Migraine attack: 
x 
An episode of any qualified migraine headache.  To distinguish an attack of long duration 
from two attacks or to distinguish between attacks and relapses:  

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o A migraine attack that is interrupted by sleep, or temporarily remits, and then 
recurs within 48 hours (i.e., <48 hours between the start of the migraine attack to 
the time of the recurrence) will be considered as one attack and not two.   
o An attack treated successfully with medication but with relapse within 48 hours 
(i.e., <48 hours between the start of the migraine attack to the time of recurrence) 
will be considered as one attack.   
 
Subjects will be advised to record their diary in the evening (after the night time dose) as a 24 
hour reflective diary entry.  For missed diary entries, subjects will be allowed to record up to 48 
hours retrospective data.  Subjects will be encouraged to record at least 80% of the daily diary 
days (80% diary compliance) during the study (from baseline to end of follow-up period) to 
remain on the study. 
11.11 Migraine Pain Intensity Score 
International Headache Society guidelines for the conduct of controlled trials of headache 
treatments recommend the use of the 4-point verbal rating scale (VRS) to measure pain intensity. 
 
Migraine pain intensity score will be recorded daily in the study diary at the times indicated in 
the Schedule of Events Table (Appendix A) beginning at Screening (V1) and daily until Follow-
Up Week 16 (End of Study; V7).  More specifically, daily assessments of migraine severity will 
be recorded in the study diary during screening, the baseline period (Day -28 to 0), prevention 
treatment period (Day 0 to 84), and follow up observation period (Day 84 to 112). 
 
4-point VRS scale for pain intensity is as follows:  
0 = no pain 
1 = mild pain (bothersome but not interfering with normal function) 
2 = moderate pain (interfering with normal function) 
3 = severe pain (requiring bedrest and unable to function) 
11.12 MIDAS 
Migraine Disability Assessment (MIDAS) questionnaire will be administered at the times 
indicated in the Schedule of Events Table (Appendix A):  Baseline (beginning of 4 week 
baseline period; V2), Randomization (end of 4 week baseline period; V3), Prevention Treatment 
Week 12 (V6), and at Unanticipated/Early Termination Visit should one occur.  The participant 
will answer a questionnaire examining the relationship between impact of migraine and quality 
of life.  
 
MIDAS questionnaire can be found in Appendix B.  
11.13 HIT-6 
Headache Impact Test-6 (HIT-6) questionnaire will be administered at the times indicated in the 
Schedule of Events Table (Appendix A): Baseline (beginning of 4 week baseline period; V2), 
Randomization (end of 4 week baseline period; V3), Prevention Treatment Week 4 (V4), 

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Prevention Treatment Week 8 (V5), Prevention Treatment Week 12 (V6), Follow-Up Week 16 
(End of Study; V7), and at Unanticipated/Early Termination Visit should one occur.  The 
participant will answer a questionnaire examining the relationship between impact of migraine 
and quality of life. 
 
HIT-6 questionnaire can be found in Appendix C.  
11.14 MSQL 
Migraine Specific Quality of Life (MSQL) questionnaire will be administered at the times 
indicated in the Schedule of Events Table (Appendix A): Baseline (beginning of 4 week baseline 
period; V2), Randomization (end of 4 week baseline period; V3), Prevention Treatment Week 4 
(V4), Prevention Treatment Week 8 (V5), Prevention Treatment Week 12 (V6), Follow-Up 
Week 16 (End of Study; V7), and at Unanticipated/Early Termination Visit should one occur.  
The participant will answer a questionnaire examining the relationship between impact of 
migraine and quality of life. 
 
MSQL questionnaire can be found in Appendix D. 
11.15 CGI 
Clinical Global Impression (CGI) scale is an investigator assessment that will be administered at 
the times indicated in the Schedule of Events Table (Appendix A): Baseline (beginning of 4 
week baseline period; V2), Randomization (end of 4 week baseline period; V3), Prevention 
Treatment Week 4 (V4), Prevention Treatment Week 8 (V5), Prevention Treatment Week 12 
(V6), Follow-Up Week 16 (End of Study; V7), and at Unanticipated/Early Termination Visit 
should one occur.  The clinician will assess measures of symptom severity, treatment response 
and the efficacy of treatments in patients. 
 
CGI scale can be found in Appendix E. 
11.16 Sample Shipment 
All laboratory testing samples are to be shipped overnight in designated temperature conditions 
to the central laboratory where samples will be analyzed.  
 
All frozen serum/plasma and nasal fluid for biomarkers are to be shipped monthly on dry ice to 
the central laboratory.  Shipments should be made only on Mondays and Tuesdays to ensure 
receipt of the specimens by Friday. 
12 SAFETY ASSESSMENTS 
12.1 Compliance 
At Randomization visit (V3), study personnel will be asked to take out all study medication 
bottles from the carton, weigh the bottles and record the weight. At each subsequent visit, study 
personnel will need to weigh the bottle without the carton and record weight.  In addition, weight 

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measurements will be performed with the protection cap and safety clip from each bottle 
removed. This procedure should be followed every time study medication returned and weighed.   
 
Participants will be asked to bring study medication with them to selected scheduled visits (V4, 
V5, V6, and Unanticipated Visit if necessary) after delivery of IP at V3.  Each site participating 
in the trial will be instructed to assess subject’s compliance by weighing the investigational 
product and obtaining the weight of the bottle in grams pre and post application during 
preventive treatment (all 3 unused bottles at visit V3 before the on-site first dose, after priming 
of first bottle at V3, after 4 weeks dosing of first bottle at V4, after 4 weeks dosing of second 
bottle at V5, and after 4 weeks dosing of third bottle at V6). Sites will be provided scales, which 
will be calibrated prior to each use. Study personnel will be instructed to record measurements 
into the eCRF. 
12.2 Safety Monitoring 
Local and systemic adverse events (AEs) related to intranasal route of administration during 
prevention treatment and follow-up will be recorded for the duration of the study from screening 
to end of follow-up. 
Safety monitoring will include infectious complications related to B244 (by symptoms and/or 
testing; pulmonary, nasal, neurological), local and systemic AEs related to intranasal route 
during treatment and at follow-up.  Local AEs include runny nose, nasal congestion, sneezing, 
nasal itching, palate itching, anosmia, nasal ulceration, nasal bleeding, sore throat, cough, Bell’s 
palsy, other neurologic complications, fevers, chills, headache, muscle aches, decreased appetite, 
nausea, vomiting, and rash.  
Sponsor will distinguish between immediate (onset of reaction is during the first 30 minutes after 
administration) and delayed (onset of action is after the first 30 minutes of administration) effects 
for safety reporting of adverse events. 
12.3 Pregnancy Reporting 
Any pregnancy will be reported by study participants during their study participation. 
Participants who report pregnancy or lactation during the review of inclusion/exclusion criteria 
prior to randomization will not be enrolled in the trial. In case of pregnancy, Investigational 
Product should be discontinued and the Sponsor informed. Follow-up of the pregnancy will be 
mandatory until the outcome is available.  
12.4 Study Completion 
A completed participant is one who has completed all study visits. Day 112 (Week 16) study 
visit is defined as the participant’s last visit (V7). 
12.5 Subject Withdrawal Criteria 
A subject may withdraw from the study at any time at his/her own request, or may be withdrawn 
at any time at the discretion of the Investigator for safety, behavioral, or administrative reasons.  
 

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Reasons for withdrawal (subjects who refuse to return for any remaining study visits) or 
discontinuation (subjects who prematurely stop the application) at any time during the study may 
include, but are not limited, to the following: 
 
 For safety reasons, either at the discretion of the Investigator or at the subject’s request 
 For protocol violations at the discretion of AOBiome 
 Due to concomitant therapy that could interfere with the results of the study (the 
Investigator will report all such information on the CRFs and decide, in accordance with 
AOBiome, whether the subject is to be withdrawn).  
All premature discontinuations and their causes must be carefully documented by the 
Investigator on the CRF or if needed on the AE form.   
 
If, for any reason, a subject is withdrawn before completing the final visit, the reason for 
termination will be entered on the CRF.  All data gathered on the subject prior to termination will 
be made available to AOBiome. Subjects not completing the entire study should be fully 
evaluated when possible.  The appropriate CRFs should be completed. 
 
If the subject chooses to withdraw before completing the study, the subject should notify the 
study coordinator who will instruct the subject on completion of assessments for 
Unanticipated/Early Termination visit (Appendix A).  For subjects who refuse to complete the 
assessments for their early termination, every attempt must be made to check on their status, 
using any mode of communication such as telephone, email, fax, or text. 
13 EFFICACY ASSESSMENTS 
Efficacy endpoints will be descriptively summarized and will include the number of 
observations, mean, median, standard deviation, minimum, and maximum of scores/values at all 
applicable time points and for all treatments in the ITT and PP Population. 
For preventive treatment, the following secondary efficacy assessments will be obtained: 
x Mean change in monthly migraine days from baseline to 12 weeks of treatment. 
x Proportion of subjects experiencing a t50%, t75%, and 100% reduction in monthly 
migraine days from baseline to 12 weeks of treatment. 
x Mean change in monthly migraine attacks from baseline to 12 weeks of treatment. 
x Mean change in monthly acute migraine specific medication days from baseline to 12 
weeks of treatment. 
x Mean change in monthly moderate and severe headache days (migraine pain-intensity 
score) from baseline to 12 weeks of treatment. 
x Mean change in monthly headache days from baseline to 12 weeks of treatment. 
x Mean change in monthly headache hours from baseline to 12 weeks of treatment. 

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x Mean change from baseline to 12 weeks of treatment in disability, as measured by the 
Migraine Disability Assessment (MIDAS) questionnaire. 
x Mean change from baseline to 12 weeks of treatment in monthly Headache Impact Test-6 
(HIT-6) questionnaire. 
x Mean change from baseline to 12 weeks of treatment in monthly Migraine Specific 
Quality of Life questionnaire (MSQL) questionnaire. 
x Mean change in baseline Clinical Global Impression (CGI) score to end of treatment 
period. 
For preventive treatment, the following exploratory efficacy assessments will be obtained: 
x 
Changes in cytokine concentration in nasal fluid and blood from baseline to 12 weeks of 
treatment. 
x 
Mean change in migraine days from end of treatment (last month of 12 weeks of 
treatment) to follow-up. 
x 
Mean change in migraine associated symptoms: nausea/vomiting, photophobia and 
sonophobia from baseline to 12 weeks of treatment. 
For the continuous endpoints of the change in migraine days, the change in migraine attacks, the 
change in days using rescue medication, the change in headache days, the change in headache 
hours, and the change in MIDAS, HIT-6, MSQL, and CGI scores, a one-sided two-sample equal-
variance z-test will be used to compare treatment group means.  Fisher’s Exact test will be used 
to make treatment group comparisons on efficacy outcomes including the following binary 
outcomes: 
x Proportion of subjects experiencing a t50%, t75%, and 100% reduction in monthly 
migraine days from baseline to 12 weeks of treatment. 
Exploratory endpoints will be analyzed using the same method as for continuous efficacy 
endpoints. The analyses will be performed on the ITT and PP population. 
14 STATISTICAL CONSIDERATIONS 
14.1 Sample Size 
Approximately 303 subjects will be enrolled in order to achieve a target sample size of 264 (i.e., 
88 subjects per arm), allowing for a 10-15% drop-out rate.  
 
Group sample sizes of 88 per arm achieve 80% power to reject the null hypothesis of equal 
means when the populatioQPHDQGLIIHUHQFHLV
1 - 2 = -3.8 - -2.3 = -1.5ZKHUH
1 = -3.8 is the 
mean reduction in migraine headache days for an active treatment aUPDQG
2 = -2.3 is the mean 
reduction in migraine headache days for placebo. The sample size calculation assumes a standard 
deviation for both groups of 4.0 and a Bonferroni adjusted significance level (alpha) of 0.05 
using a one-sided two-sample equal-variance z-test.  Testing each active treatment arm versus 
vehicle at an adjusted significance level of 0.05 maintains an overall error rate of 0.10. 

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14.2 Populations for Analysis 
Male and female subjects, 18 to 65 years of age, with a history of episodic migraine are eligible 
for enrollment.   
ITT: includes all randomized participants who receive at least 1 dose of study medication.   
Safety: includes all subjects who received at least 1 dose of study medication.  
Per Protocol: subjects who administered at least 50 % of IP (based on the weight of IP used), 
have completed their Week 12 visit, and did not have any major protocol violations.  
14.3 Data Analysis 
The analyses will be conducted on all participant data when the trial ends.  Data will be 
presented by treatment group and overall.   
 
Categorical variables will be summarized by frequency distributions (number and percentages of 
subjects) and continuous variables will be summarized by descriptive statistics (mean, standard 
deviation etc). 
 
Adverse events will be summarized by treatment using the Medical Dictionary for Regulatory 
Activities (MedDRA) system organ class and preferred term. Separate tabulations will be 
produced for all treatment-emergent AEs (TEAEs), treatment-related AEs (those considered by 
the Investigator as at least possibly drug related), SAEs, discontinuations due to AEs, and AEs 
*UDGHVHYHULW\%\
-subject listings will be provided for any deaths, SAEs, and AEs leading to 
discontinuation. 
 
Descriptive statistics will be provided for clinical laboratory values (e.g., hematology, serum 
chemistry, and urinalysis) and vital signs data, presented as both actual values and changes from 
baseline relative to each on-study evaluation. Abnormal clinical laboratory values will be listed.  
 
All data will be provided in by-subject listings. 
14.3.1 Disposition 
A tabulation of the disposition of subjects will be presented, including the number enrolled, 
the number randomized, the number treated, and the reasons for study discontinuation will be 
reported. Summaries of the number in each analysis set will be summarized. Entry criteria 
and protocol deviations will be listed. 
14.3.2 Demographic and Baseline 
Demographic and baseline characteristic data summarization will be performed in order to 
descriptively assess the comparability of the treatments. Data to be tabulated will include 
age, race, ethnicity, height, weight, and BMI, as well as baseline characteristics related to 
medical history. 

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14.4 Safety Analyses 
The primary endpoint is safety, as assessed by incidence and severity of AEs, physical 
examination, neurological examination, and vital signs (blood pressure, heart rate, respiratory 
rate).  A secondary safety endpoint is safety assessments after 28 day follow-up period. 
 
The analysis of safety will be based on the safety population, which is defined as all subjects 
receiving at least 1 dose of B244 or Vehicle. Adverse events (AEs) will be coded using the 
Medical Dictionary for Regulatory Activities (MedDRA®) for purposes of summarization. All 
AEs occurring during the study will be included in by-subject data listings and tabulated. Events 
leading to death, serious AEs, and events resulting in study discontinuation will be summarized 
using standard descriptive statistics, and presented by treatment arm. Exposure to study drug and 
reasons for discontinuation of study treatment will be tabulated. Shift tables relative to the 
normal range will be provided for laboratory parameters.  Additional analyses will be performed, 
if warranted, upon review of the data. 
14.4.1 Definitions  
All adverse events recorded during the study will be coded according to Medical Dictionary 
for Regulatory Activities.  
 
The primary analysis of safety will be based on the safety population, which is defined as all 
subjects receiving at least 1 dose of B244 or placebo. Adverse events (AEs) will be coded 
using the Medical Dictionary for Regulatory Activities (MedDRA®) for purposes of 
summarization. All AEs occurring during the study will be included in by-subject data 
listings and tabulated. Events leading to death, SAEs, and events resulting in study 
discontinuation will be summarized using standard descriptive statistics, and presented by 
treatment arm. Exposure to study drug and reasons for discontinuation of study treatment will 
be tabulated. Shift tables relative to the normal range will be provided for laboratory 
parameters.  Additional analyses will be performed, if warranted, upon review of the data. 
14.4.2 Adverse Events  
All adverse events (AEs) recorded during the study through the date of randomization 
through 28 days after the last dose of study drug will analyzed.  
 
All AE’s will be coded according to Medical Dictionary for Regulatory Activities and 
summarized using System Organ Class (SOC) and Preferred Term (PT).  
 
AE’s will be summarized using incidence rates. Therefore, each subject will only contribute 
once for a given adverse event SOC or PT.  
 
A summary of the incidence of any adverse event, SAE, and adverse events leading to 
discontinuation will be presented.  Summaries will display, by treatment, the incidence of 
patients with events, the frequency of patients with events within each primary system organ 
class and by preferred terms. For each preferred term and each system organ class a patient 

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will be counted only once. For summaries on severe or drug-related AE, for a given patient, 
the highest severity or relationship for a specific preferred term will be considered.  
14.4.3 Deaths and Serious Adverse Events  
Serious adverse events and events leading to death will be summarized overall and by 
primary system organ class and preferred term.  
14.4.4 Adverse Events Leading to Treatment Discontinuation  
Adverse events leading to treatment discontinuation will be summarized overall and by 
primary system organ class and preferred term.  
14.5 Efficacy Analyses 
Efficacy analyses will be performed on the intent-to-treat (ITT) population, which consists of all 
randomized subjects who receive at least 1 dose of study medication, and on the per protocol 
(PP) population, which consists of subjects who complete their Week 12 visit and have percent 
FRPSOLDQFH
 50% (based on the weight of IP used).  For the continuous endpoints of the change 
in migraine days, the change in migraine attacks, the change in days using rescue medication, the 
change in headache days, the change in headache hours, and the change in MIDAS, HIT-6, 
MSQL, and CGI scores, a one-sided two-sample equal-variance z-test will be used to compare 
treatment group means.  Fisher’s Exact test will be used to make treatment group comparisons 
for the following binary outcomes: 
x Proportion of subjects experiencing a t50%, t75%, and 100% reduction in monthly 
migraine days from baseline to 12 weeks of treatment. 
Exploratory endpoints will be analyzed using the same method as for continuous efficacy 
endpoints. The analyses will be performed on the ITT and PP population. 
14.5.1 Handling of Dropouts or Missing Data  
Missing data will not be imputed for analysis.  
 
Subjects who dropout after enrollment but prior to randomization will be replaced.  
14.6 Clinical Trial Protocol Deviations  
All the following deviations will be summarized on the all randomized patient population:  
 
x 
Inclusion or exclusion criteria not satisfied.  
x 
Deviations related to the Investigational Product administration  
x 
Not permitted concomitant medications.  

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15 ADVERSE EVENTS (AE) AND SERIOUS ADVERSE EVENTS (SAE) 
The Investigator and study staff are responsible for detecting and recording AEs and SAEs 
during scheduled safety evaluations and whenever such information is brought to their attention. 
This section of the protocol provides definitions and detailed procedures to be followed. 
15.1 Definition of an AE 
An AE is any untoward medical occurrence in a study participant which is temporally associated 
with the use of a medicinal product, regardless of its potential relationship to the medicinal 
product.  An AE, therefore, can be any unfavorable or unintended sign, including an abnormal 
symptom, or disease (new or exacerbated), whether or not related to the investigational product 
(IP).   
 
Examples of an AE include: 
 Exacerbation of a pre-existing condition including either an increase in frequency and/or 
intensity of the condition. 
 New conditions detected or diagnosed after investigational product administration even 
though it may have been present prior to the start of the study. 
 Signs, symptoms of a drug interaction. 
 Signs, symptoms of a suspected overdose of either investigational product or a concurrent 
medication (overdose per se should not be reported as an AE/SAE). 
AEs may include pre- or post-treatment events that occur as a result of protocol-mandated 
procedures (i.e., modification of participant’s previous therapeutic regimen). 
15.2 Definition of a SAE 
A serious adverse event is any untoward medical occurrence that, at any dose: 
(a) results in death. 
(b) is life-threatening. 
NOTE:  The term 'life-threatening' in the definition of 'serious' refers to an event in which the 
participant was at risk of death at the time of the event.  It does not refer to an event, which 
hypothetically might have caused death, if it were more severe. 
 
(c) requires hospitalization or prolongation of existing hospitalization. 
NOTE:  In general, hospitalization signifies that the participant has been detained (usually 
involving at least an overnight stay) at the hospital or emergency ward for observation and/or 
treatment that would not have been appropriate in the physician’s office or out -patient setting.  
Complications that occur during hospitalization are AEs.  If a complication prolongs 
hospitalization or fulfills any other serious criteria, the event is serious.  When in doubt as to 
whether “hospitalization” occurred or was necessary, the AE should be considered serious. 
Routine hospitalizations or elective surgeries are generally not regarded as SAEs.  

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(d) results in disability/incapacity, or 
NOTE:  The term disability means a substantial disruption of a person’s ability to conduct 
normal life functions.  This definition is not intended to include experiences of relatively minor 
medical significance such as uncomplicated headache, nausea, vomiting, diarrhea, influenza, and 
accidental trauma (e.g. sprained ankle) which may interfere or prevent everyday life functions 
but do not constitute a substantial disruption. 
(e) is a congenital anomaly/birth defect 
(f) Medical or scientific judgment should be exercised in deciding whether reporting is 
appropriate in other situations, such as important medical events that may not be 
immediately life-threatening or result in death or hospitalization but may jeopardize the 
participant or may require medical or surgical intervention to prevent one of the other 
outcomes listed in the above definition.  These should also be considered serious.  Examples 
of such events are invasive or malignant cancers, intensive treatment in an emergency room 
or at home for allergic bronchospasm, blood dyscrasias or convulsions that do not result in 
hospitalization, or development of drug dependency or drug abuse. 
15.3 Time Period, Frequency, and Method of Detecting AEs and SAEs 
All AEs occurring after administration of the first dose of study medication and on or before the 
final assessment must be reported as AEs.  All AEs must be recorded irrespective of whether 
they are considered drug-related. 
 
At each assessment in the period defined above, AEs will be evaluated by the Investigator and 
recorded. 
 
Any AEs already documented at a previous assessment and designated as ongoing, should be 
reviewed at subsequent assessments as necessary.  If these have resolved, this should be 
documented.  Changes in intensity or frequency of AEs should be recorded as separate events 
(i.e., a new record started). 
 
The recording of AEs and SAEs are described in Section 15.4 (“Recording of AEs and SAEs”). 
15.4 Recording of AEs and SAEs 
All clinical events, including either observed or volunteered problems, complaints or symptoms 
are to be recorded on the Adverse Events page(s) of the CRF.  The need to capture this 
information is not dependent upon whether the clinical event is associated with study treatment. 
Adverse clinical events resulting from concurrent illnesses or reactions to concurrent 
medications are also to be recorded.  In order to avoid vague, ambiguous, or colloquial 
expressions, the AE should be recorded in standard medical terminology rather than the 
participant’s own words. 
 
Each adverse clinical event is to be evaluated for duration, intensity, and whether the event may 
be associated with the investigational product (IP) or other causes.  Start and stop dates, 

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relationship to investigational product (IP), medical management, and alternative causality of 
event must be recorded in the Adverse Events section of the CRF.  AEs believed to be possibly 
related to investigational product (IP) must be followed until resolution. 
15.5 Evaluating AEs and SAEs 
15.5.1 Severity Rating 
The severity of an adverse event (AE and SAE) is to be scored according to the following 
scale: 
Mild 
Awareness of sign or symptom, but easily tolerated 
Moderate 
Discomfort enough to cause interference with usual 
activity 
Severe 
Incapacitating with inability to work or perform usual 
activity 
 
Potentially 
Life 
Threatening 
 
Life threatening consequences; urgent intervention 
indicated 
Fatal 
Death related to AE 
 
An AE that is assessed as severe should not be confused with a SAE.  An event is defined as 
‘serious’ when it meets one of the pre-defined outcomes as described in Section 15.2 
“Definition of a SAE”. 
15.5.2 Relationship to Investigational product (IP)  
SAEs will be classified as “definitely not related”, “unlikely related”, “possibly related”, 
“probably related”, or “definitely related” (including unknown).  
 
For AEs, the relationship to study treatment is to be assessed according to the following 
definitions: 
 
Definitely not related: The AE is definitely not related to the drug.  This designation 
should be reserved for those events which occur prior to study treatment or for those 
events which cannot be even remotely related to study participation (e.g., injuries 
sustained in an automobile accident). 
Unlikely related: There is no reasonable association between the study treatment and the 
suspected event and the event could have been produced by the participant 's clinical state 
or other modes of therapy administered to the participant. 

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Possibly related:  The suspected adverse event may or may not follow a reasonable 
temporal sequence from study treatment administration but seems to be the type of 
reaction that cannot be dismissed as unlikely.  The event could have been produced or 
mimicked by the participant 's clinical state or by other modes of therapy concomitantly 
administered to the participant. 
Probably related: The suspected adverse event follows a reasonable temporal sequence 
from study treatment administration, abates upon discontinuation of the treatment, and 
cannot be reasonably explained by the known characteristics of the participant 's clinical 
state. 
Definitely related: This designation should be reserved for those events which have no 
uncertainty in their relationship to treatment administration. 
15.6 Pregnancy 
Any pregnancy that occurs in a female participating in the study must be reported to the Sponsor 
within 3 working days of learning of the pregnancy. Follow-up must occur to determine the 
outcome of the pregnancy (including premature termination) and the status of mother and child.  
Pregnancy complications and elective terminations for medical reasons must be reported as AEs 
or SAEs. Spontaneous abortions must be reported as an SAE. 
Any SAE occurring in association with a pregnancy and considered by the Investigator as 
possibly related or related to the investigational product must be promptly reported to the 
Sponsor, even if the event occurred after the participant completed the study. 
The Investigator must attempt to collect pregnancy information on any female partners of male 
participants who become pregnant while the male participant is enrolled in the study. Pregnancy 
information must be reported to the Sponsor as described above. 
15.7 Prompt Reporting of SAEs to the Sponsor 
In the case of a Serious Adverse Event the Investigator must immediately: 
x
SEND (within 1 working day, by fax) the signed and dated corresponding page(s) in the
Case Report Form to the representative of the Monitoring Team whose name, address and
fax number appear on the Clinical Trial Protocol (Larry Weiss, MD,
safety@aobiome.com; 617-475-1605), or to a designated Safety contact provided by the
Monitoring Team, as well as to the Central Database number;
x
ATTACH a photocopy of all examinations carried out and the dates on which these
examinations were performed. Care should be taken to ensure that the patient's identity is
protected and the patient's identifiers in the Clinical Trial are properly documented on all
copies of source documents provided to the Sponsor. For laboratory results, include the
laboratory normal ranges;
x
Follow-up of any Serious Adverse Event that is fatal or life threatening should be
provided within one additional calendar week. The treatment code will be unblinded for
reporting of Serious Adverse Events that are unexpected and reasonably associated with
the use of the Investigational Product. 

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Follow-up 
x
The Investigator should take all appropriate measures to ensure the safety of the patients,
including referral to a specialist if indicated. Notably he/she should follow up the
outcome of any adverse events (clinical signs, laboratory values or other, etc) until the
return to normal or stabilization of the patient's condition;
x
In the case of any serious adverse event, the patient must be followed up until clinical
recovery is complete and laboratory results have returned to normal, or until progression
has been stabilized. This implies that follow-up may continue after the patient has left the
Clinical Trial and that additional investigations may be requested by the Monitoring
Team;
x
In case of any serious adverse event brought to the attention of the Investigator at any
time after cessation of Investigational Product and considered by him/her to be caused by
the Investigational Product with a reasonable possibility, this should be reported to the
Monitoring Team.
Primary Contact 
AOBiome Reportable Events Hotline 
24 Hour Phone: 617-475-1605 
Email: safety@aobiome.com  
Call medical monitor to email a scanned report 
16 ETHICAL AND REGULATORY STANDARDS 
16.1 Ethical Conduct of Study 
This clinical trial was designed and shall be implemented, executed, and reported in accordance 
with the ICH Harmonized Tripartite Guidelines for Good Clinical Practice, with applicable local 
regulations (including US Code of Federal Regulations Title 21), and with the ethical principles 
laid down in the Declaration of Helsinki. 
The Investigator(s) should conduct the study in accordance with this protocol, the Declaration of 
Helsinki and ICH GCP guidelines and FDA regulations.  The Investigator(s) and the Sponsor 
will sign the protocol and study contract, to confirm agreement.  The Investigator(s) will not 
implement any amendment (deviation or changes of the protocol) without agreement by the 
Sponsor and IRB approval, except where necessary to eliminate immediate hazard(s) to study 
participants, or when change(s) involve only logistical or administrative aspects of the study. 

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Records that may reveal the identities of participants must be well protected, with consideration 
given to confidentiality and the right to privacy of participants. 
16.2 Laws and Regulations 
This Clinical Trial will be conducted in compliance with all international laws and regulations, 
and national laws and regulations of the countries in which the clinical trial is performed, as well 
as any applicable guidelines. The trial will be registered and updated on www.clintrials.gov and 
on other sites, as deemed appropriate.  
16.3 Informed Consent 
Each participant must be provided with a statement that the investigation involves research and 
that the IRB has approved solicitation of participants to participate; a fair explanation of the 
procedures to be followed and their purposes, including identification of any procedures which 
are experimental; a description in lay language of any possible side effects; a description of any 
attendant discomforts and risks reasonably to be expected; a description of any benefits 
reasonably to be expected; a disclosure of any appropriate alternative procedures that might be 
advantageous for the participant; an offer to answer any inquiries concerning the procedures, and 
instruction that the person is free to withdraw consent and discontinue participation in the project 
or activity at any time without prejudice to the participant.  Payment to research participants for 
taking part in the study is based on time and inconvenience.   All information concerning 
payment, including the schedule of payments, must be set forth in the informed consent, 
including a disclosure that the Investigator is being paid to perform the stated research. 
 
A participant must give consent to take part in the study.  Participants below the age of majority 
in the municipality must give written assent to participate in this study.  This consent must be 
dated and retained by the Principal Investigator as part of the study records.  A downloadable 
digital copy shall be given to the person signing the form.  The informed consent process must be 
documented in the participant’s source documents. 
 
The Investigator agrees that the Sponsor, its employees or agents will have the right from time to 
time during the course of this study to audit and review pertinent medical records relating to this 
clinical trial.  A statement will be obtained from each person participating in the study permitting 
the release of his/her medical records as necessary for inspection by authorized personnel of the 
Sponsor, FDA, and the staff managing the clinical study.  
 
The release of medical records and the review of the contents will be in compliance with the 
Health Insurance Portability and Accountability Act of 1996 (HIPAA). 
16.4 Institutional Review Board/Independent Ethics Committee (IRB/EC) 
The protocol and informed consent form and the electronic version of the consent for this study 
must be approved by the IRB.  A copy of the Letter of Approval from the Board, which contains 
specific identification of the documents approved, must be received by the Sponsor prior to 
shipment of drug supplies to the Principal Investigator. 
 

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All changes to the protocol, as well as a change of Investigator, must also be approved by the 
IRB and documentation of this approval provided to the study monitor.  Records of the IRB’s 
review and approval of all documents pertaining to the study must be kept on file by the 
Principal Investigator and are subject to FDA inspection at any time.  IRB renewal for approval 
is required each year.  The Investigator is to notify AOBiome, in writing, of the approval to 
continue the study.   
16.5 Clinical Monitoring/Record Keeping 
There shall be no alterations in the protocol design without the written consent and approval of 
the Sponsor and the approval of the IRB, except in the case that participants are at immediate 
risk without immediate implementation of such alterations.  In the aforementioned situation, the 
site should notify the Sponsor and IRB of the deviation as soon as possible, and should seek the 
written consent and approval of the Sponsor and the approval of the IRB. 
 
All results of this trial must be recorded on eCRFs.  Each participant who has been randomized 
must have a completed eCRF.  Reasons for termination must be stated in the early termination 
section.  Study participants are not to be identified by name on eCRFs, but rather by coded 
identifiers and participant initials.   
 
The study monitor will verify the accuracy of the data by reviewing pertinent source documents 
such as office records or hospital charts of the participants. 
 
Study records include eCRFs, signed FDA Form 1572, original reports of test results, and 
digitally signed electronic informed consent forms.  IRB approval letters and other documents 
pertaining to the conduct of the study are to be kept on file by the Investigator.   If the study files 
are assigned to someone else or removed to another location, the Investigator is to notify the 
study monitor or Sponsor in writing of the change.  All study records are subject to FDA 
inspection at any time. 
 
All information supplied to the Investigator by the Sponsor before, during, and after the study is 
confidential.  Such information is to be used solely in connection with the clinical study.  The 
study protocol, IB, and any other pertinent study related materials or records provided are to be 
maintained in a confidential manner, reviewed carefully with attention to admonitions and 
returned to the Sponsor upon request.  No part of these materials may be reproduced or 
transmitted in any form without prior written permission from the Sponsor. 
17  ADMINISTRATIVE RULES 
17.1 Curriculum Vitae 
An updated, signed, and dated copy of the curriculum vitae limited to the experience, 
qualification and training for each Investigator and/or Sub-Investigator(s) will be provided to the 
Sponsor prior to the beginning of the Clinical Trial.  
17.2 Archiving of Study Documentation 

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The Investigator must maintain confidential all study documentation, and take measures to 
prevent accidental or premature destruction of these documents.  
 
It is recommended that the Investigator retain the study documents at least fifteen (15) years after 
the completion or discontinuation of the Clinical Trial. However, applicable regulatory 
requirements should be taken into account in the event that a longer period is required.  
 
The Investigator must notify the Sponsor prior to destroying any study essential documents 
within the fifteen (15) year period following the Clinical Trial completion or discontinuation.  
 
If the Investigator's personal situation is such that archiving can no longer be ensured by him/her, 
the Investigator shall inform the Sponsor and the relevant records shall be transferred to a 
mutually agreed upon designee.  
17.3 Internal Safety Review Committee 
An internal safety review committee may be set up as needed to protect the ethical and safety 
interests of participants and to protect the scientific validity of the study. Ad-hoc safety interim 
analyses might be performed by an independent statistician if the safety review committee 
identifies potential safety signals during its routine blinded safety review. The details for the 
analysis plan will be documented in the trial’s Statistical Analysis Plan. 
18 STUDY MONITORING 
18.1 Responsibilities of the Investigator(s)  
The Investigator(s) undertake(s) to perform the Clinical Trial in accordance with this Clinical 
Trial Protocol, ICH guidelines for Good Clinical Practice and the applicable regulatory 
requirements.  
 
The Investigator is required to ensure compliance with all procedures required by the Clinical 
Trial Protocol and by study procedures provided by the Sponsor (including security rules). The 
Investigator agrees to provide reliable data and all information requested by the Clinical Trial 
Protocol (with the help of the Case Report Form [CRF], Discrepancy Resolution Form [DRF] or 
other appropriate instrument) in an accurate and legible manner according to the instructions 
provided and to ensure direct access to source documents to Sponsor representatives. If any 
particular circuits have to be defined (e.g., e-CRF, Fax), particular attention should be paid to the 
confidentiality of the patient's data to be transferred. The Investigator may appoint such other 
individuals as he/she may deem appropriate as Sub-Investigators to assist in the conduct of the 
Clinical Trial in accordance with the Clinical Trial Protocol. All Sub-Investigators shall be 
timely appointed and listed. The Sub-Investigators will be supervised by and under the 
responsibility of the Investigator. The Investigator will provide them with a Clinical Trial 
Protocol and all necessary information.  
18.2 Responsibilities of the Sponsor  

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The Sponsor of this Clinical Trial is responsible to Health Authorities for taking all reasonable 
steps to ensure the proper conduct of the Clinical Trial Protocol with regard to ethics, Clinical 
Trial Protocol compliance, integrity and validity of the data recorded on the Case Report Forms. 
Thus, the main duty of the Monitoring Team is to help the Investigator and the Sponsor maintain 
a high level of ethical, scientific, technical and regulatory quality in all aspects of the Clinical 
Trial. At regular intervals during the Clinical Trial, the site will be contacted, through monitoring 
visits, letters or telephone calls, by a representative of the Monitoring Team to review study 
progress, Investigator and patient compliance with Clinical Trial Protocol requirements, and any 
emergent problems. During these monitoring visits, the following but not exhaustive list of 
points will be scrutinized with the Investigator: patient informed consent, patient recruitment and 
follow-up, Serious Adverse Event documentation and reporting, outcome events documentation 
and reporting, Investigational Product allocation, patient compliance with the Investigational 
Product regimen, Investigational Product accountability, concomitant therapy use and quality of 
data.  
18.3 Source Document Requirements  
According to the ICH guidelines for Good Clinical Practice, the Monitoring Team must check 
the Case Report Form entries against the source documents, except for the preidentified source 
data directly recorded in the Case Report Form. The Informed Consent Form will include a 
statement by which the patient allows the Sponsor’s duly authorized personnel, the Ethics 
Committee (IRB/EC), and the regulatory authorities to have direct access to source data which 
supports the data on the Case Report Forms (e.g., patient's medical file, appointment books, 
original laboratory records, etc.). These personnel, bound by professional secrecy, must keep 
confidential all personal identity or personal medical information (according to confidentiality 
rules).  
18.4 Use and Completion of Case Report Forms (CRFs) and Additional Requests  
The sponsor or CRO will be responsible for activities associated with the data management 
of this study. This will include setting up a relevant database and data transfer mechanisms, 
along with appropriate validation of data and resolution of queries. Data generated within this 
clinical study will be handled according to the relevant SOPs of the data management and 
biostatistics departments of sponsor or CRO. 
  
For Electronic Data Capture (EDC): 
Study sites will enter data directly into an EDC system by completing the eCRF via a secure 
internet connection.  Data entered into the eCRF must be verifiable against source documents 
at the study site. Any changes to the data entered into the EDC system will be recorded in an 
automated, secure audit trail and is Food and Drug Administration (FDA) Code of Federal 
Regulations (CFR) Title 21 Part 11 compliant. 
  
Data entered into the eCRF will be validated as defined in the Data Validation Specifications 
(DVS). Validation includes, but is not limited to, validity checks (for example, missing data, 
range checks) and consistency checks (logical checks between variables) to ensure that study 
data are accurately reported. Additionally, CRO Data Management will perform aggregate data 
review as defined in the DVS to ensure that the data are complete, consistent and reasonable. The 

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electronic edit checks will run continually throughout the course of the study and queries 
reviewed by CRO personnel to assure validity as compared to source records. Manual queries 
may also be entered into EDC by Monitoring or Data Management personnel to address 
identified discrepancies. 
  
Medical conditions/procedures will be coded using MedDRA and prior and concomitant 
medications will be coded using WHODrug. 
  
At the conclusion of the study, each site will be provided with their subject CRFs in Portable 
Document Format (PDF) for archival.  The CRF PDFs will contain subject data, audit trail 
information, queries including responses, and comments. 
19 PUBLICATIONS 
All data generated from this study are the property of AOBiome LLC and shall be held in strict 
confidence along with all information furnished by AOBiome.  Independent analyses and/or 
publication of these data by the Investigator or any member of his/her staff is not permitted 
without prior written consent of AOBiome.   
 
Any formal presentation or publication of data from this trial will be considered as a joint 
publication by the Investigator(s) and appropriate Sponsor personnel.  Authorship will be 
determined by mutual agreement. Written permission to the Investigator will be contingent on 
the review by the Sponsor of the methodology and statistical analysis and any publication or 
presentation will provide for nondisclosure of AOBiome confidential or proprietary information.  
In all cases, the parties agree to submit all manuscripts or abstracts to all other parties at least 30 
days prior to submission.  This will enable all parties to protect proprietary information and to 
provide comments based on information that may not yet be available to other parties.   
20 PROTOCOL ADHERENCE 
This protocol defines the study objectives, the study procedures and the data to be collected on 
study participants. Additional assessments required to ensure safety of participants should be 
administered as deemed necessary on a case by case basis. Under no circumstances is an 
Investigator allowed to collect additional data or conduct any additional procedures for any 
research related purpose involving any investigational drugs under the protocol. 
 
Investigators ascertain they will apply due diligence to avoid protocol deviations. If an 
Investigator feels a protocol deviation would improve the conduct of the study this must be 
considered a protocol amendment, and unless such an amendment is agreed upon by the sponsor 
and approved by the IRB/IEC and health authorities, where required, it cannot be implemented. 
21 CONFIDENTIALITY  
All information disclosed or provided by the Sponsor (or any company/institution acting on their 
behalf), or produced during the Clinical Trial, including, but not limited to, the Clinical Trial 
Protocol, the CRFs, the Investigator's Brochure and the results obtained during the course of the 
Clinical Trial, is confidential. The Investigator or any person under his/her authority agrees to 

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undertake to keep confidential and not to disclose the information to any third party without the 
prior written approval of the Sponsor. However, the submission of this Clinical Trial Protocol 
and other necessary documentation to the Ethics Committee (IRB/EC) is expressly permitted, the 
IRB/EC members having the same obligation of confidentiality. The Sub-Investigators shall be 
bound by the same obligation as the Investigator. The Investigator shall inform the Sub-
Investigators of the confidential nature of the Clinical Trial. The Investigator and the Sub-
Investigators shall use the information solely for the purposes of the Clinical Trial, to the 
exclusion of any use for their own or for a third party's account. 
22 PROPERTY RIGHTS  
All information, documents and Investigational Product provided by the Sponsor or its designee 
are and remain the sole property of the Sponsor. The Investigator shall not mention any 
information or the Product in any application for a patent or for any other intellectual property 
rights. All the results, data, documents and inventions, which arise directly or indirectly from the 
Clinical Trial in any form, shall be the immediate and exclusive property of the Sponsor. The 
complete verified database will be shared with the Operations Committee, which shall have full 
access to all data. The Sponsor may use or exploit all the results at its own discretion, without 
any limitation to its property right (territory, field, continuance). The Sponsor shall be under no 
obligation to patent, develop, market or otherwise use the results of the Clinical Trial. As the 
case may be, the Investigator and/or the Sub-Investigators shall provide all assistance required by 
the Sponsor, at the Sponsor's expense, for obtaining and defending any patent, including 
signature of legal documents.  
23 DATA PROTECTION  
The patient's personal data and Investigator's personal data which may be included in the 
Sponsor database shall be treated in compliance with all applicable laws and regulations;  
 
When archiving or processing personal data pertaining to the Investigator and/or to the patients, 
the Sponsor shall take all appropriate measures to safeguard and prevent access to this data by 
any unauthorized third party.  
24 SPONSOR AUDITS AND INSPECTIONS BY REGULATORY AGENCIES  
For the purpose of ensuring compliance with the Clinical Trial Protocol, Good Clinical Practice 
and applicable regulatory requirements, the Investigator should permit auditing by or on the 
behalf of the Sponsor and inspection by applicable regulatory authorities.  
 
The Investigator agrees to allow the auditors/inspectors to have direct access to his/her study 
records for review, being understood that this personnel is bound by professional secrecy, and as 
such will not disclose any personal identity or personal medical information.  
 
The Investigator will make every effort to help with the performance of the audits and 
inspections, giving access to all necessary facilities, data, and documents. As soon as the 
Investigator is notified of a future inspection by the authorities, he will inform the Sponsor and 
authorize the Sponsor to participate in this inspection.  

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The confidentiality of the data verified and the protection of the patients should be respected 
during these inspections.  
 
Any result and information arising from the inspections by the regulatory authorities will be 
immediately communicated by the Investigator to the Sponsor.  
 
The Investigator shall take appropriate measures required by the Sponsor to take corrective 
actions for all problems found during the audit or inspections.  
25 PREMATURE DISCONTINUATION OF THE STUDY OR PREMATURE CLOSE-
OUT OF A SITE 
25.1 Decided by the Sponsor in the Following Cases: 
1. In the event the results of the Clinical Trial do not appear to be scientifically convincing 
to the Sponsor;  
2. If the aim of the Clinical Trial has become outdated or is no longer of interest;  
3. If the information on the product leads to doubt as to the benefit/risk ratio;  
4. If the Investigator has received from the Sponsor all Investigational Product, means and 
information necessary to perform the Clinical Trial and has not included any patient after 
a reasonable period of time mutually agreed upon;  
5. In the event of breach by the Investigator of a fundamental obligation under this 
agreement, including but not limited to breach of the Clinical Trial Protocol, breach of 
the applicable laws and regulations or breach of the ICH guidelines for GCP;  
6. If the total number of patients are included earlier than expected; In any case the Sponsor 
will notify the Investigator of its decision by written notice.  
25.2 Decided by the Investigator  
The Investigator must notify (30 days' prior notice) the Sponsor of his/her decision and give the 
reason in writing. In all cases (decided by the sponsor or by the Investigator), the appropriate 
Ethics Committee(s) (IRB/EC) and Health Authorities should be informed.  
26 CLINICAL TRIAL PROTOCOL AMENDMENTS  
Any protocol amendments will be added as stand-alone documents.  In addition, any and all 
revisions dictated by the amendments will be made in the protocol.  Each time a protocol is 
amended, a new amended version date will be added to the cover page. 
 
All appendices attached hereto and referred to herein are made part of this Clinical Trial 
Protocol. The Investigator should not implement any deviation from, or changes of the Clinical 
Trial Protocol without agreement by the sponsor and prior review and documented 
approval/favorable opinion from the IRB/EC of an amendment, except where necessary to 
eliminate an immediate hazard(s) to clinical trial patients, or when the change(s) involves only 
logistical or administrative aspects of the trial. Any change agreed upon will be recorded in 

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writing, the written amendment will be signed by the Investigator and by the Sponsor and the 
signed amendment will be filed with this Clinical Trial Protocol. Any amendment to the Clinical 
Trial Protocol requires written approval/favorable opinion by the IRB/EC prior to its 
implementation, unless there are overriding safety reasons. In some instances, an amendment 
may require a change to the Informed Consent Form. The Investigator must receive an IRB/EC 
approval/favorable opinion concerning the revised Informed Consent Form prior to 
implementation of the change. 
 
 

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27 APPENDIX A-SCHEDULE OF EVENTS 
 

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Visit name (Day) 
Screening 
 
Baseline 
(Beginning of 
4 week 
baseline 
period) 
Randomization    
(End of 4 week 
baseline period) 
Prevention 
Treatment 
Week 4 
 
Prevention 
Treatment 
Week 8 
Prevention 
Treatment 
Week 12 
Follow-Up 
(End of 
Study) 
Week 16  
 
Unanticipated/Early 
Termination Visit 
Visit 
V1  
(Day -29) 
V2  
(Day -28) 
V3  
(Day 0) 
V4  
(Day 28) 
V5 
(Day 56) 
V6 
(Day 84) 
V7 
(Day 112) 
 
Visit Window, in 
Days 
-42 to -28  
-31 to -27 
r3 
r3 
 
r3 
r3 
r3 
 
Informed Consent1 
X 
 
 
 
 
 
 
 
Inclusion/Exclusion 
Criteria2 
O 
X 
X17 
 
 
 
 
 
Demographics 
O 
 
 
 
 
 
 
 
Medical history 
O 
 
 
 
 
 
 
 
Smoking status 
O 
 
 
 
 
 
 
 
Concomitant 
medications 
O 
X 
X 
X 
 
X 
X 
X 
O 
Vital signs (HR, 
BP, respiratory 
rate) 
X 
O 
X 
X 
X 
X 
X 
O 
Brief Physical 
exam 
X 
X 
X 
X 
X 
X 
X 
O 

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Neurological exam 
X 
X 
X 
X 
X 
X 
X 
X 
Body weight 
X 
X 
X 
X 
X 
X 
X 
O 
Height 
X 
 
 
 
 
 
 
 
Blood collection3 
 
 
X 
X 
X 
X 
X 
X 
12-lead ECG 
X 
 
X 
 
 
X 
 
 
Randomization4 
 
 
X 
 
 
 
 
 
Nasal inspection5 
X 
X 
X 
X 
X 
X 
X 
X 
Delivery of 
Investigational 
Product 
 
 
X 
 
 
 
 
 
Investigational 
Product 
application6 
 
 
X 
X 
X 
X 
 
 
Investigational 
Product 
compliance7 
 
 
X 
X 
X 
X 
 
X 
Counseling8 
 
 
X 
X 
X 
 
 
X 
Laboratory testing9 
X 
 
X 
 
 
X 
 
X 
Urinary pregnancy 
test10 
X 
 
 
 
 
 
 
 
Nasal fluid11 
 
 
X 
X 
X 
X 
X 
X 
Safety AEs 
X 
X 
X 
X 
 
X 
X 
X 
X 

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Study diary12 
X 
X 
X 
X 
 
X 
X 
X 
X 
Migraine pain 
intensity score 
X 
X 
X 
X 
 
X 
X 
X 
X 
MIDAS13 
 
X 
X 
 
 
X 
 
X 
HIT-614 
 
X 
X 
X 
X 
X 
X 
X 
MSQL15 
 
X 
X 
X 
X 
X 
X 
X 
CGI16 
 
X 
X 
X 
X 
X 
X 
X 
Subject Satisfaction 
Survey 
 
 
 
 
 
 
X 
X18 

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1. Informed consent can be obtained up to 14 days prior to the baseline visit (V2). 
2. Inclusion and exclusion criteria will be reviewed at Screening (V1), Baseline (V2), and Randomization (V3) visits to make sure nothing changed. 
3. Blood samples for biomarkers will be collected and processed on site. Serum/plasma samples will be frozen onsite and shipped to the Central lab 
for storage.   
4. Subject’s demographic data and medical history are blinded to the statistician for randomization and treatment assignment.  Only subjects with 4-
14 migraine headache days per month during baseline period (28 days between V2 and V3) will be randomized. 
5. Nasal inspection will include clinical examination of the nasal mucosa, sinuses, and upper airway using an otoscope. 
6. Subjects will be trained for in-home treatment/assessment on the use of the nasal spray, and have their first dose of treatment on site (V3).  
Subjects will remain onsite for observation for 1 hour post dosing. Subjects will then be dispensed study medication for 12 weeks of at home dosing.  
7. Weight of individual IP bottles will be obtained at visits V3 (before and after first dose), V4, V5, V6, and unanticipated/early termination visit.   
8. Subjects will be counseled on the application of the nasal spray, study diary, and answer any questions. 
9. Fasting blood sample for a comprehensive metabolic panel, complete blood count, chemistry, lipid panel, and liver function test-15 ml.  Also 
includes urinalysis.  Patients should fast for at least 8 hours before the test. Blood will be shipped to the central lab for processing. 
10. Urine pregnancy test to be done on WOCBP. 
11. Intranasal strip will be used to collect nasal fluid for inflammatory cytokines.  Optionally, nasal fluid may be evaluated for nasal microbiome 
(e.g., PCR) to confirm presence of B244. 
12. Subjects will be asked to fill out a daily migraine-history diary from screening to treatment with study drug and a migraine-treatment diary from 
treatment through the remainder of the follow-up period. Baseline period, prevention treatment, and follow up observation period for study 
assessments will be daily and will include dosing, migraine days, headache days, migraine intensity, headache intensity, rescue meds (acute migraine 
specific meds), nausea, vomiting, photophobia, and sonophobia.  Collect sufficient information about the headache in the trial (i.e., headache 
intensity, presence/absence of associated symptoms, unilateral/bilateral location, aggravation by exercise, throbbing/non-throbbing) to verify the 
headache is a migraine. 
13. Migraine Disability Assessment questionnaire. 
14. Headache Impact Test-6 questionnaire. 
15. Migraine Specific Quality of Life questionnaire. 
16. Clinical Global Impression scale 
17. Subjects are randomized upon confirming the inclusion/exclusion criteria and the entry criteria of 4-14 migraine headache days during the 
baseline period. 
18. Only for Early Termination Visit due to study discontinuation or withdrawal.

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28 APPENDIX B- MIGRAINE DISABILITY ASSESSMENT (MIDAS) 
QUESTIONNAIRE 
 
The Migraine Disability Assessment Test  
The MIDAS (Migraine Disability Assessment) questionnaire was put together to help you 
measure the impact your headaches have on your life. The information on this questionnaire is 
also helpful for your primary care provider to determine the level of pain and disability caused 
by your headaches and to find the best treatment for you.  
INSTRUCTIONS  
Please answer the following questions about ALL of the headaches you have had over the last 3 
months. Select your answer in the box next to each question. Select zero if you did not have the 
activity in the last 3 months. Please take the completed form to your healthcare professional.  
1. On how many days in the last 3 months did you miss work or school because of your 
headaches?  
2. How many days in the last 3 months was your productivity at work or school reduced by half 
or more because of your headaches? (Do not include days you counted in question 1 where you 
missed work or school.)  
3. On how many days in the last 3 months did you not do household work (such as housework, 
home repairs and maintenance, shopping, caring for children and relatives) because of your 
headaches?  
4. How many days in the last 3 months was your productivity in household work reduced by half 
of more because of your headaches? (Do not include days you counted in question 3 where you 
did not do household work.)  
5. On how many days in the last 3 months did you miss family, social or leisure activities 
because of your headaches?  
Total (Questions 1-5)  
What your Physician will need to know about your headache:  
• On how many days in the last 3 months did you have a headache? (If a headache lasted more 
than 1 day, count each day.) R 
• On a scale of 0 - 10, on average how painful were these headaches? (where 0=no pain at all, 
and 10= pain as bad as it can be.) R 

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Scoring: After you have filled out this questionnaire, add the total number of days from 
questions 1-5 (ignore A and B).  
 
 
 
 
 
 
 
 
MIDAS Grade  
  
Definition  
MIDAS Score  
I  
Little or No Disability  0-5  
II  
Mild Disability  
6-10  
III  
Moderate Disability  
11-20  
IV  
  
Severe Disability  
21+  
If Your MIDAS Score is 6 or more, please discuss this with your doctor.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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29 APPENDIX C- HEADACHE IMPACT TEST-6 (HIT-6) QUESTIONNAIRE 
 
HIT-6 Questionnaire (Evaluation of headache disability)RThis questionnaire was designed to 
help you describe and communicate the way you feel and what you cannot do because of 
headaches.R 
INSTRUCTIONS : To complete, please circle one answer for each question.  
1. When you have headaches, how often is the pain severe?  
Never   
Rarely  
Sometimes  
 
Very often  
 
Always  
2. How often do headaches limit your ability to do usual daily activities including household 
work, work, school, or social activities?  
Never   
Rarely  
Sometimes  
 
Very often  
 
Always  
3. When you have a headache, how often do you wish you could lie down?  
Never   
Rarely  
Sometimes  
 
Very often  
 
Always  
4. In the past 4 weeks, how often have you felt too tired to do work or daily activities because of 
your headaches?  
Never   
Rarely  
Sometimes  
 
Very often  
 
Always  
5. In the past 4 weeks, how often have you felt fed up or irritated because of your headaches?  
Never   
Rarely  
Sometimes  
 
Very often  
 
Always  
6. In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily 
activities?  
Never   
Rarely  
Sometimes  
 
Very often  
 
Always  
Column 1 
Column 2  
Column 3  
 
Column 4  
 
Column 5  
Column 1 (Never): 6 points each  
 
______  
Column 2 (Rarely): 8 points each  
 
______  

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Column 3 (Sometimes): 10 points each  
______  
Column 4 (Very often): 11 points each  
______  
Column 5 (Always): 13 points each   
______  
To score, add points for answers in each column.  
Total Score: ________  
Class I: 36-49, Class II: 50-55, Class III: 56-59, Class IV: 60 and more.  
It is suggested to talk to your physician for class II and more.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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30 APPENDIX D- MIGRAINE SPECIFIC QUALITY OF LIFE (MSQL) 
QUESTIONNAIRE 
 
MIGRAINE SPECIFIC QUALITY OF LIFE QUESTIONNAIRE (VERSION 2.1)  
PATIENT INSTRUCTIONS:  
Please fill out this questionnaire. It will help us understand the effects of migraine 
headache on your daily activities.  
The questionnaire has been designed so that it can be completed quickly and easily. Please 
check only one answer for each question. You should answer every question.  
Thank you for your time.  
While answering the following questions, please think about all migraine attacks you may have 
had in the past 4 weeks.  
1. In the past 4 weeks, how often have migraines interfered with how well you dealt with 
family, friends and others who are close to you? (Select only one response.) R1  None 
of the timeR2  A little bit of the time 3  Some of the timeR4  A good bit of the 
time 5  Most of the timeR6  All of the time R 
2. In the past 4 weeks, how often have migraines interfered with your leisure time 
activities, such as reading or exercising? (Select only one response.) R1  None of the 
timeR2  A little bit of the time 3  Some of the timeR4  A good bit of the time 
5  Most of the timeR6  All of the time R 
3. In the past 4 weeks, how often have you had difficulty in performing work or daily 
activities because of migraine symptoms? (Select only one response.) R1  None of the 
timeR2  A little bit of the time 3  Some of the timeR4  A good bit of the time 
5  Most of the timeR6  All of the time R 
4. In the past 4 weeks, how often did migraines keep you from getting as much done at 
work or at home? (Select only one response.) R1  None of the timeR2  A little bit 
of the time 3  Some of the timeR4  A good bit of the time 5  Most of the 
timeR6  All of the time R 

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5. In the past 4 weeks, how often did migraines limit your ability to concentrate on work or 
daily activities? (Select only one response.) R1  None of the timeR2  A little bit of 
the time 3  Some of the timeR4  A good bit of the time 5  Most of the 
timeR6  All of the time R 
6. In the past 4 weeks, how often have migraines left you too tired to do work or daily 
activities? (Select only one response.) R1  None of the timeR2  A little bit of the 
time 3  Some of the timeR4  A good bit of the time 5  Most of the 
timeR6  All of the time R 
7. In the past 4 weeks, how often have migraines limited the number of days you have felt 
energetic? (Select only one response.) R1  None of the timeR2  A little bit of the 
time 3  Some of the timeR4  A good bit of the time 5  Most of the 
timeR6  All of the time R 
8. In the past 4 weeks, how often have you had to cancel work or daily activities because 
you had a migraine? (Select only one response.) R1  None of the timeR2  A little 
bit of the time 3  Some of the timeR4  A good bit of the time 5  Most of the 
timeR6  All of the time R 
9. In the past 4 weeks, how often did you need help in handling routine tasks such as every 
day household chores, doing necessary business, shopping, or caring for others, when you 
had a migraine? (Select only one response.) R1  None of the timeR2  A little bit of 
the time 3  Some of the timeR4  A good bit of the time 5  Most of the 
timeR6  All of the time R 
10. In the past 4 weeks, how often did you have to stop work or daily activities to deal with 
migraine symptoms? (Select only one response.) R1  None of the timeR2  A little 
bit of the time 3  Some of the timeR4  A good bit of the time 5  Most of the 
timeR6  All of the time R 
11. In the past 4 weeks, how often were you not able to go to social activities such as parties, 
dinner with friends, because you had a migraine? (Select only one response.) 
R1  None of the timeR2  A little bit of the time 3  Some of the timeR4  A 
good bit of the time 5  Most of the timeR6  All of the time R 
12. In the past 4 weeks, how often have you felt fed up or frustrated because of your 

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migraines? (Select only one response.) R1  None of the timeR2  A little bit of the 
time 3  Some of the timeR4  A good bit of the time 5  Most of the 
timeR6  All of the time R 
13. In the past 4 weeks, how often have you felt like you were a burden on others because of 
your migraines? (Select only one response.) R1  None of the timeR2  A little bit of 
the time 3  Some of the timeR4  A good bit of the time 5  Most of the 
timeR6  All of the time R 
14. In the past 4 weeks, how often have you been afraid of letting others down because of 
your migraines? (Select only one response.) R1  None of the timeR2  A little bit of 
the time 3  Some of the timeR4  A good bit of the time 5  Most of the 
timeR6  All of the time R 
 
 

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31 APPENDIX E- CLINICAL GLOBAL IMPRESSION (CGI) SCALE 
 
CLINICAL GLOBAL IMPRESSION 
 
1. Severity of illness  
Considering your total clinical experience with this particular population, how mentally ill is the 
patient at this time?  
0 = Not assessedR1 = Normal, not at all ill 2 = Borderline mentally ill 3 = Mildly ill  
4 = Moderately illR5 = Markedly illR6 = Severely illR7 = Among the most extremely ill patients  
2. Global improvement: Rate total improvement whether or not, in your judgement, it is due 
entirely to drug treatment. Compared to his condition at admission to the project, how much has 
he changed?  
0 = Not assessedR1 = Very much improved 2 = Much improvedR3 = Minimally improved  
4 = No changeR5 = Minimally worse 6 = Much worseR7 = Very much worse  
3. Efficacy index: Rate this item on the basis of drug effect only.RSelect the terms which best 
describe the degrees of therapeutic effect and side effects and record the number in the box 
where the two items intersect.REXAMPLE: Therapeutic effect is rated as ‘Moderate’ and side 
effects are judged ‘Do not significantly interfere with patient’s functioning’.  
Therapeutic effect 
Side effects 
None  
Do not 
significantly 
interfere with 
patient’s 
functioning 
Significantly 
interferes 
with 
patient’s 
functioning  
Outweighs 
therapeutic 
effect 
Marked 
Vast improvement. 
Complete or nearly 
complete remission 
of all symptoms 
01  
02  
03  
04  
Moderate 
Decided 
improvement. 
05  
06  
07  
08  

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Partial remission of 
symptoms 
Minimal 
Slight improvement 
which doesn’t alter 
status of care of 
patient 
09  
10  
11  
12  
Unchanged or 
worse 
13  
14 
15  
16 
Not assessed = 00 
 
 

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