Novel Insight Into Migraine Pathophysiolgy and Galcanezumab Mechanisms of Action
Phase: PHASE4
Conditions: Chronic Migraine
Sponsor: Beth Israel Deaconess Medical Center

(CCI) Committee on Clinical Investigations 
Page 1 of 12 
 
Study Description – Part B 
CCI Form:  9-2015 
 
PI Revision Date: 11/2/2021 
 
PART B 
STUDY DESCRIPTION 
 
TITLE OF PROTOCOL 
Novel insight into migraine pathophysiology and galcanezumab 
mechanisms of action      
Principal Investigator 
Rami Burstein, PhD 
 
B1. 
PURPOSE OF PROTOCOL 
The purpose of this study is to understand better the mechanisms of action of calcitonin gene related peptide 
(CGRP) targeted monoclonal antibodies in migraine prevention. Specifically, the protocol will allow us to 
determine whether the main site of action of this novel and recently-approved class of migraine prophylactic 
drugs act inside or outside the brain and if so, where.     
 
B2. 
SIGNIFICANCE AND BACKGROUND FOR THE STUDY 
The migraine brain exhibits unique sets of structural and functional changes involving multiple nuclei in the 
brainstem, thalamus, hypothalamus, and basal ganglia as well as cortical areas that mediate many of the 
migraine associated symptoms, prodrome and auras.  Currently, there is an ongoing academic debate over 
cause and effect in the pathophysiology of chronic migraine.  This debate is based on 2 different hypotheses: 
(a) hypothesis one suggests that the migraine brain is inherently hyperexcitable, and that this inherent 
hyperexcitability is the cause of the headache as well as all the changes seen in migraine brain imaging.  In 
contrast, (b) hypothesis two suggests that the continuous bombardment of the brain by pain signals that 
originate in the meninges and transferred to the dorsal horn, brainstem, thalamus, hypothalamus, basal ganglia 
and cortex is the cause of all the changes seen in the structure and function of the migraine brain.   
 
Until recently, it was not possible to resolve this debate as no research tools existed that allowed us to 
distinguish clearly between peripheral and central contributions to the state of the migraine brain.  The 
introduction of anti-CGRP monoclonal antibodies (anti-CGRP-mAbs) to our clinical ammunition against chronic 
migraine, however, have changed this situation.  Because CGRP-mAbs are too large to cross the blood brain 
barrier - at least to the extent that their concentration and distribution in the different brain areas are large 
enough to generate a therapeutic effect – but nevertheless, can effectively render a significant number of 
patients completely or almost completely headache-free (i.e., the super-responders: defined as those whose 
migraine days per month decrease by 75, 90 or 100%), it is now generally acceptable that while migraine attack 
(prodromes, aura, sensory sensitivities) can originate in abnormal brain functioning, the headache itself 
depends entirely on activation of pain fibers that carry pain signals from the meninges and potentially other 
pain-sensitive structures in the head, to the spinal cord and brain.   
 
Our working hypothesis is that many of the structural and functional abnormalities observed in the migraine 
brain are secondary to the continuous bombardment of the brain with pain signals that originate in the 
meninges.  To test this hypothesis, we propose to determine whether structural and functional brain changes 
seen in individual chronic migraine (CM, ≥15 headache days/month) and high-frequency episodic migraine 
(HFEM, 10 to 14 headache days/month) patients are reversed in those cases in which galcanezumab therapy 
was super-effective but not in those in which galcanezumab therapy was ineffective (part 1 – imaging).  We 
also propose to determine whether galcanezumab therapy eliminated interictal hypersensitivities, prodromes 
and auras as well as common triggers in patients in which this therapy was super-effective vs. patients in which 
it was not effective et al (part 2 – neurological evaluation).  The importance of these studies is that they can 
help us understand better the migraine brain, migraine pathophysiology, and anti-CGRP-mAbs mechanisms of 
action in the prevention of migraine. 
 
To test our working hypothesis more thoroughly, we will also determine whether the extent of structural and 
functional brain changes seen after 3 months of treatment; the reduction in interictal hypersensitivities; and/or 
the ability of prodromes, auras, and common triggers to predict or initiate attacks continue to improve over time 
in the responder group. 
 
 
 

(CCI) Committee on Clinical Investigations 
Page 2 of 12 
 
Study Description – Part B 
CCI Form:  9-2015 
 
PI Revision Date: 11/2/2021 
 
B3. 
DESCRIPTION OF RESEARCH PROTOCOL 
A. 
Study Design – Overview, Methods, Procedures 
 
a.  
 
A brief overview of the study: To test our working hypothesis, we propose to study 160 CM/HFEM 
patients in up to 14 visits to the Beth Israel Deaconess Medical Center (BIDMC) Comprehensive 
Headache Center and up to 4 visits to the research MRI center in the Ansin Building at BIDMC. The 
first 2 visits to the BIDMC Comprehensive Headache Center and the first visit to BIDMC research 
MRI center will take place before treatment and the 5th visit to BIDMC Comprehensive Headache 
Center and the second visit to the research MRI center will take place 3 months after initiation of 
treatment. In these visits, we will collect medical and headache history, perform a physical 
examination, administer and review subjects’ e-diary, and perform functional and structural MRI of 
the brain. As a precaution for COVID, patients will have the option of choosing to conduct the 3rd and 
4th study visits (2nd and 3rd study medication injections) remotely via StarLeaf or over the phone 
instead of coming to the headache clinic. Participants who reach certain thresholds over the course 
of their three months of treatment with the study medication may also continue with a study extension 
of up to nine months, where they will continue to receive monthly doses of the study drug while 
continuing the e-diary. Participants who end the study treatment either prior to the end of the third 
dose or during the study extension will be asked to conduct an end of treatment visit, where they will 
complete a final MRI scan and attend a study conclusion visit with the PI. 
 
 
Overall study design: Experimental prospective study involving identification of neurological effects 
after treatment of CM and HFEM with galcanezumab – an anti-CGRP-mAb.    
 
 
Design methodologies: Open-label treatment study comparing the effects of galcanezumab on 
neurological functioning and brain structure in super-responders, responders and non-responders 
among CM and HFEM patients.  
  
 
Primary goal: (1) To determine whether galacanezumab – a drug that acts mainly outside the brain 
- reverses abnormal brain functioning in CM and HFEM patients.  For this study, signs of abnormal 
brain functioning include triggering of migraine by deviation from homeostasis (prodromes, sleep 
deprivation, skipping meals) and abnormal sensitivity to sensory stimuli (light, noise, smell, auras). 
(2) To determine whether the extent of structural and functional brain changes seen after 3 months 
of treatment; the reduction in interictal hypersensitivities; and/or the ability of prodromes, auras, and 
common triggers to predict or initiate attacks continue to improve over time by comparing results 
seen at 3 and 6 months after treatment initiation in the responder and super-responder groups.  For 
ethical reasons, we will not continue with treatment (beyond 3 months) in the non-responders.  
 
 
Key details of study implementation: The study includes CM and HFEM patients. The intervention is 
galacanezumab (Emgality™). Galcanezumab is an anti-CGRP-mAb approved by the FDA for the 
prophylactic treatment of migraine. Because this is not an efficacy study, the primary endpoint will 
not include reduction in number of migraine/headache days per month.  Rather, the primary 
endpoints of the study will include the following: incidence of prodromes, incidence of triggers, 
sensitivity to light, noise and smell during and in between attacks, and incidence of aura (as 
determined by filling the e-diary), gray mater thickness and connectivity strength between brain 
areas involved in migraine (as determined by MRI). Each patient will be scheduled to visit the 
headache clinic at BIDMC up to 8 times and the BIDMC research MRI center for three of those visits. 
The initial baseline visit at the Headach Center will take 1 hour. Follow up visits at the headache 
clinic, during which participants will receive doses of the study drug, will take 30 min. Visits that 
include an MRI scan (which take place before treatment, as well as 3, 6, and 12 months after 
treatment, will take 2 and a half hours. In addition, each patient will have to fill a daily diary for up to 
13 months (estimated to take 5 minutes per day) and will receive a 5 minute weekly phone call from 
a study coordinator. 
 Note: Subjects that completed the first four months of the study prior to the approval of the 
study extension will be asked to sign a new consent form that includes information about 
the study extension prior to continuing with their study participation. These participants, all 
of whom are patients of Dr. Ashina, had been clinically prescribed with the medication after 
completion of the initial study treatment, which is in accordance with what the doctor would 

(CCI) Committee on Clinical Investigations 
Page 3 of 12 
 
Study Description – Part B 
CCI Form:  9-2015 
 
PI Revision Date: 11/2/2021 
 
typically prescribe. This only applies to the first eight enrolled patients, who concluded their 
initial study participation between 12/7/20 and 1/4/21. 
 
b. Participants will undergo the following procedures:  
1. Medical and Headache history at the Headache Center (questionnaire filled by patients and reviewed 
by Drs. Ashina and Burstein) 
2. Physical examination including measurements of vital signs at the Headache Center  (performed by 
Dr. Ashina) 
3. Undergo Quantitative Sensory testing (QST) at the beginning of the study and after each MRI scan 
(performed by Dr. Ashina) 
a. QST will be done in a quiet room away from noise and distraction. Patients will be able to 
choose their most comfortable position (sitting on a chair or laying in bed) during the sensory 
testing. In each testing session, pain thresholds to hot and mechanical stimulation will be 
determined in the skin over the site to where the pain is referred to. This site includes most 
commonly the periorbital and temporal regions. Heat skin stimuli will be delivered through a 
30x30 mm2 thermode (Q-Sense 2016, Medoc) attached to the skin at a constant pressure 
and their pain thresholds will be determined by using the Method of Limit. The equipment 
used for quantitative sensory testing has an FDA approval. It imposes no risk or discomfort, 
and since the patient controls it, stimuli can be stopped at any time. 
b. To determine pain thresholds, the skin will be allowed to adapt to a temperature of 32C/89.6°F 
for 5 minutes and then warmed up at a slow rate (1 C/sec) to a maximum of 50C/122°F or until 
pain sensation is perceived, at which moment the subject stops the stimulus by pressing a button 
on a patient response unit. If the subject does not stop the heat stimulus before it reaches 
50C/122°F, the device will automatically shut off and return the heat stimulus to a temperature 
of 32C/89.6°F within a second. This will prevent burns from occurring to the subjects, as a 
50C/122°F should not cause a burn, even if it stays at this temperature for 30 seconds. Heat 
stimuli will be repeated three times each and the mean of recorded temperatures will be 
considered threshold. Pain threshold to mechanical stimuli will be determined by using a set of 
20 calibrated von Frey hairs (VFH, Stoelting).  Each VFH monofilament is assigned a scalar 
number in an ascending order (1 = 0.0045g, 2 = 0.023g, 3 = 0.027g, 4 = 0.07g, 5 = 0.16g, 6 = 
0.4g, 7 = 0.7g, 8 = 1.2g, 9 = 1.5g, 10 = 2.0g, 11 = 3.6g, 12 = 5.4g, 13 = 8.5g, 14 = 11.7g, 15 = 
15.1g, 16 = 28.8g, 17 = 75g, 18 = 125g, 19 = 281g).  Because a linear relationship exists between 
the log force and the ranked number, mechanical pain thresholds are expressed as VFH 
numbers (#) rather then their forces (g).  Each monofilament will be applied to the skin 3 times 
(for 2 sec) and the smallest VFH number capable of inducing pain at two out of three trials will 
be considered threshold.  Skin sensitivity will also be determined by recording patient’s 
perception of soft skin brushing, which is a dynamic mechanical stimulus, as distinguished from 
the VFH, which is a static mechanical stimulus.    
4. E-diary education and administration by study coordinator at the Headache Center 
a. The e-diary will be administered in the form of a REDCap survey using an email link that 
participants can access from their personal computer/electronic device 
b. The e-diary will consisted of a questionnaire that will ask questions concerning any headaches 
that the participant has experienced that day and any remedies that they undertook to relieve 
their pain 
5. Undergo urine pregnancy testing at the research MRI center prior to the MRI scans 
6. Up to 4 MRI sessions at the research MRI center run by Dr. Nicolas Bolo. We will recruit a healthy 
volunteer to do a phantom run of the imaging protocol. 
a. During the two month research MRI shutdown starting in August, we will increase the scanning 
window by a month to compensate for the unavailability of the scanner. This change will not 
negatively impact the research, as subjects will remain on study treatment. 
b. Any scans projected to occur during this time span that cannot be pushed back by a month will 
be performed using the clinical MRI on the West campus. The research MRI team will help 
coordinate these scans. 
7. Administration of galcanezumab loading dose by Dr. Ashina at the Headache Center. 
8. Self administration of galcanezumab maintenance doses at home. These doses will be shipped to 
subjects’ residences ahead of their monthly dosage days. The study team will obtain the study 
medication from the Research pharmacy via the usual SOP and mail it to the subjects via a traceable 
method at ambient storage. As the study medication may be stored at room temperature for 7 days, 

(CCI) Committee on Clinical Investigations 
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Study Description – Part B 
CCI Form:  9-2015 
 
PI Revision Date: 11/2/2021 
 
supply will be mailed within close proximity to the “visit” day. The sponsor has approved the 
aforementioned plan. Subjects will have the option to come in to the headache clinic for the visit if 
they so wish. 
 
c. 
Imaging part of the study:  
Patients recruited to the study and deemed eligible to participate (per the results of visit 1),  
will have MRI visits scheduled at the research MRI center for the MRI scanning.  All MRI scanning will take 
place at BIDMC under the supervision of our Co-investigator Dr. Nicolas Bolo. Subjects will be met by the 
study coordinator and be escorted to the MRI scanning area. The BIDMC MRI staff will review the subject’s 
MRI safety checklist and prep the subjects for scanning. As per the chart flow above, each patient will be 
scanned at least twice, once before initiation of treatment with galcanezumab and a second time on day 120 
of the study, after being on galcanezumab for about 3 months. Participants that continue with the study 
extension will undergo two additional scans, one on day 210 and another on day 390. 
Image acquisition will be performed with a General Electric 3 Tesla MRI scanner (GE Discovery 
MR750) equipped with a 32-channel proton head coil.  For each patient, a series of high resolution structural, 
functional and metabolic imaging and spectroscopy scans of the brain will be acquired.  Image acquisition 
will take 1-hour scanning time, including patient preparation and positioning.   
Processing and analyses of brain imaging and spectroscopy scans will be performed with  
specialized software packages to yield morphometric, functional and metabolic brain measures.  
Analysis of the brain images obtained from the MRI scans may be conducted by either Dr.  
Borsook at Boston Children’s Hospital or Dr. Bolo at BIDMC. A data transfer agreement has been arranged 
between BIDMC and Boston Children’s for the transfer of these images. 
 
Study 
Timeline 
Day 0: 
Screenin
g 
(Headac
he 
Center) 
Day 30: 
MRI 
scan and 
initial 
dosing 
(BIDMC) 
Days 60 
and 90: 
Mainten
ance 
dose 
(Home/B
IDMC) 
Day 120: 
MRI 
scan and 
mainten
ance 
dose/stu
dy 
conclusi
on visit 
for non-
respond
ers 
(BIDMC) 
Day 150 
and 180: 
Mainten
ance 
dose 
(Home/B
IDMC) 
Day 210: 
MRI 
scan and 
mainten
ance 
dose/stu
dy 
conclusi
on visit 
for non-
respond
ers 
(BIDMC) 
Day 240, 
270, 
300, 
330, 
360: 
Mainten
ance 
dose 
(Home/B
IDMC) 
Day 390: 
MRI 
scan and 
study 
conclusi
on visit 
(BIDMC) 
End of 
Treatme
nt Visit 
Informed 
consent  
X 
 
 
 
 
 
 
 
 
Physical 
examinat
ion 
X 
 
 
X 
 
X 
 
X 
X 
Vital 
signs 
X 
 
 
X 
 
X 
 
X 
X 
Review 
of 
medical 
and 
headach
e history 
X 
 
 
X 
 
X 
 
X 
X 
QST 
X 
 
 
X 
 
X 
 
X 
X 
Administ
ration of 
e-diary 
X 
 
 
 
 
 
 
 
 
Review 
of e-
diary 
 
X 
 
X 
 
X 
 
X 
X 

(CCI) Committee on Clinical Investigations 
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Study Description – Part B 
CCI Form:  9-2015 
 
PI Revision Date: 11/2/2021 
 
Review 
of 
inclusion
/ 
exclusio
n criteria 
 
X 
 
 
 
 
 
 
 
Urine 
pregnan
cy 
testing 
 
X 
 
X 
 
X 
 
X 
 
MRI 
scan 
 
X 
 
X 
 
X 
 
X 
X 
Drug 
administr
ation 
 
X1 
 
X1 
 
X1 
X1 
X1 
X1 
 
 
e-diary 
completi
on 
X2 
 
 
1. Home dosing will be assisted over the phone by the PI or subjects have the option to come into the clinic 
2. Subjects will receive weekly phone calls and a reminder email from the coordinator about completing the 
diaries. 
 
Incidental findings: Participants will be informed of any findings, such as inter-cranial abnormalities, and the PI 
will make the necessary referrals. 
 
 
B. 
Statistical Considerations 
 
a. Sample Size Justification: This study will enroll a total of 160 patients with chronic and high-frequency 
episodic migraine and 1 additional volunteer to complete a dry run of the scanning sequences.   
 
 
Overall Clinical Assessment: The required sample size estimate has been obtained to provide sufficient 
power to evaluate several inferences estimated within two statistical models. The overall alpha level (
 
= 0.05) is preserved through sequential omnibus testing of the proposed hypotheses. Essentially, we are 
evaluating whether there is an association between degree of response and the probability of 
experiencing four equally important binary outcomes: 1) photophobia, (2) phonophobia, (3) nausea, and 
(4) at least one or more triggers. In model 1, inferences will be conducted based on the association of 
the degree of response to treatment (i.e., 0 to 100% response in headache frequency) and changes in 
these outcomes over time (0 vs 3 months). In model two, individuals who respond to treatment at 3 
months will be further observed at 6 months to examine differences in the outcomes over time. 
 
In a study by Rasmussen et al, 83.2% of migraine patients experienced photophobia, 82.4% of migraine 
patients experienced nausea and 85.7% experienced phonophobia. Additionally, in a 2007 study by 
Kelman et al, 75.9% of patients reported one or more trigger using an unstructured recall. Thus, the event 
rates for each of the primary outcomes are expected to be in the interval of 76% to 86%. To test our 
working hypotheses, we will enroll 160 CM/HFEM patients. This sample size is selected because it is 
anticipated that a substantial number of participants will be lost to screen failures, attrition or other drop-
out.  Based on previous studies it is expected that of the enrolled patients, 67% will be responders (> 
50% improvement) and 33% will be non-responders. These patients will undergo the repeated brain 
scans and the identification of changes in neurological functioning, associated symptoms, prodromes 
and triggers. These patients will be scanned at week 12, while still on the galcanezumab therapy and 
then interviewed regarding their neurological functioning (Visit 3). Our goal is to have at least n = 30 
responders who belong to the >75% super-responder group, n= 30 > 50% but less than 75% responders, 
and n = 20 non-responders. 

(CCI) Committee on Clinical Investigations 
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Study Description – Part B 
CCI Form:  9-2015 
 
PI Revision Date: 11/2/2021 
 
 
Enrolling N = 160 individuals is expected to yield N = 80 evaluable individuals at 3 months. This sample 
size provides 80% power to detect an absolute difference in paired proportions (i.e., baseline vs 3 
months) of 11%, assuming a baseline proportion of 80%, two-sided alpha = 0.05, and a within-subject 
correlation of r = 0.75. Using these assumptions, this sample size also provides 80% power to detect an 
odds ratio from the continuous headache frequency change predictor of OR>=1.95.  
 
 
Sample Size Justification (fMRI): We estimated the sample size for the proposed work using previous 
pseudo-continuous arterial spin labelling data collected in migraine patients (N=17) and matched, healthy 
control (HCs, N=17) (Hodkinson et al., PlosOne, 2015).  We calculated cerebral blood flow (CBF) in 
primary somatosensory cortex [means ± standard deviations (SD), ml/100g/min] in migraine (44.59 ± 
9.67) and HCs (33.03 ± 10.97); effect size (Cohen’s d) =1.12). We used the larger SD of the two cohorts 
to calculate the sample size and estimated 15 patients per group to detect a difference in CBF in primary 
somatosensory cortex with 80% statistical power at the 5% significance level.  Similarly, Based on or 
prior data for a 6-year bracket, the expected variability in volumes is of the order of 1.8 and 1.5%, 
respectively. For SI, with an effect size of 0.83, to achieve 80% power while maintaining 95% confidence 
we need to acquire 20 subjects per group.  
 
b. Data Collection and Analysis: The following data will be collected before and after treatment: triggers, 
prodromes, associated symptoms, cortical thicknesses, and visual cortex activation magnitude.  Of these, 
primary endpoints include freedom from triggers and prodromes, and cortical thickness recovery.  
Secondary endpoints include reduction in migraine associated symptoms (defined as sensitivity to light, 
noise and smell) and reduction in activation magnitude of the visual cortex.  For each of these parameters, 
analyses will compare between the groups (>75% responders, >50% responders, non-responders). 
 
c. Details of data collection in the imaging study: 
 
1. 3-Plane Localizer – 3 min 
Fast Gradient-Echo sequence 
Parameters: Slices = 5 in each of the sagittal, coronal, axial planes, slice thickness = 5 mm, no gap, FOV 
= 260 mm.  
The localizer scan is used to determine the position of the subject’s head in the scanner, readjust the 
subject’s position to the magnetic center of the scanner if needed, and position the subsequent images. 
 
2. Calibration scan – 2 min 
SPGR (Spoiled Gradient) sequence 
Parameters: FOV = 300 mm, slice thickness = 9.4 mm. 
This scan is used to calibrate the transmit/receive channels for parallel imaging using the ASSET option 
of the GE scanner. 
 
3. T1-weighted Structural – 7 min  
MPRAGE (Magnetization Prepared Rapid Gradient Echo) sequence / Accelerated sagittal IR-FSPGR 
(Inversion Recovery – Fast Spoiled Gradient) sequence 
Parameters: Sagittal slices = 176, slice thickness = 1 mm, no gap, FOV field of view = 256 x 256 mm, TE 
echo time = 1.74 ms, TI inversion time = 400 ms, TR repetition time = 2520 ms, flip angle  = 11°, resolution 
= 1 x 1 mm, voxel size = 1 x 1 x 1 mm, receiver bandwidth = 31.25 Hz.   
The T1-weighted image is used for morphometric analyses (primary outcome = regional cortical 
thickness). 
This iso-voxel GE implementation of the MPRAGE sequence follows the ADNI-3 protocol. 
 
4. T2-weighted FLAIR – 6 min  
FLAIR (Fluid Attenuated Inversion Recovery) / Cube T2 FLAIR sequence 
Parameters: Sagittal slices = 176, FOV = 256 x 256 mm, slice thickness = 1 mm, no gap, voxel size = 1 
x 1 x 1 mm, TE = 119 ms, TR = 4800 ms, TI = 1473 ms, receiver bandwidth = 31.25 Hz. 
The FLAIR image is used for morphometric analyses by providing a high-resolution T2-weighted contrast 
image to resolve dura and vessels from cortical gray matter.  This improves the reliability of the cortical 
thickness analyses. It is also used to detect lesions and help identify the nature of incidental findings of 
structural anomalies. Follows the ADNI-3 protocol.  

(CCI) Committee on Clinical Investigations 
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Study Description – Part B 
CCI Form:  9-2015 
 
PI Revision Date: 11/2/2021 
 
 
5. Single voxel MRS – 10 min 
PRESS (Point Resolved Spectroscopy) sequence. 
Parameters: Single voxel located in the occipital lobe centered on the primary visual area, oblique voxel 
size = 24 x 25 x 35 mm (21 mL), TE = 30 ms, TR = 2000 ms, 128 averages.  For each water-suppressed 
scan, a water non-suppressed scan is acquired for use in water scaling to obtain absolute concentrations 
of metabolites (units of mmol/kg wet-weight brain).  Time takes into account ~5 minutes for positioning 
of voxel and adjusting field homogeneity and transmitter power.   
The single voxel MRS is used for regional brain metabolite analysis (17 metabolites including glutamate, 
N-acetylaspartate, total creatine, choline containing compounds and myo-inositol). GABA is not reliably 
determined.  
 
6. Single voxel GABA-edited MRS – 11 min 
MEGA-PRESS (Mescher-Garwood PRESS) sequence 
Parameters: Single voxel with same location as scan 5, TE = 68 ms, TR = 2000 ms, 256 averages (128 
ON – 128 OFF), editing pulses applied at 1.9 (ON) and 1.5 (OFF) ppm, macromolecule suppression on.  
For each water-suppressed scan, a water non-suppressed scan is acquired for use in water scaling to 
obtain absolute concentrations of metabolites (units of mmol/kg wet-weight brain). 
The MEGA-PRESS MRS is used for regional brain GABA concentration analysis. 
 
7. Cerebral Blood Flow (CBF) – 6 min 
PCASL (Pseudo-Continuous Arterial Spin Labeling) 3D stack of spirals sequence 
Parameters: Aaxial slices = 34, FOV = 240 x 240 mm, slice thickness = 4 mm, no gap, voxel size = 3.75 
x 3.75 x 3.75 mm, TE = 9.8 ms, TR = 6000 ms, labeling duration = 1800 ms, post-labeling delay = 1800 
ms, flip angle = 90º, spin labeling slab located 10 mm below cerebellum.   
This PCASL scan is used for whole brain quantitative CBF analyses. 
 
Total scan time = 45 min (leaves required 15 min for scanner setup and break-down in 1 hour slot) 
 
Descriptive statistics of the data will be performed and presented. Continuous data will be reported as 
means ± standard deviations or medians (interquartile ranges) and assessed with a parametric t-test or 
non-parametric equivalent. Differences before and after treatment will be assessed in paired tests, as 
appropriate. Additionally, in subgroup analyses, differences between all three groups (>75% responders, 
>50% responders, non-responders) will be assessed using analysis of variance (ANOVA) or Kruskal-
Wallis tests. Categorical data will be presented as frequencies and proportions and assessed with a chi-
square or Fisher’s Exact test. 
 
In order to assess our four primary outcomes over time and in relation to the differences observed 
conditional on the degree of response to galcanezumab, multivariate generalized linear modeling will be 
employed using generalized estimating equations (GEE). These models will consider the four binary 
outcomes simultaneously by specifying a binary outcome with a log link function. Fixed effects for time 
(0, 3, 6, 12 months), degree of response (headache frequency: coded as number of headache days), 
baseline headache frequency, and time x degree of response will be specified in the model. Participants 
will be the unit of clustering (to account for the repeated measures) with an AR1 covariance matrix to 
account for the expected degree of autocorrelation in the measurement occasions. An omnibus test for 
a shared effect (i.e., a joint change in all outcomes) will be conducted with sensitivity analyses considering 
measure-specific effects (i.e., a degree of change x outcome interaction). In this way, we will be able 
examine the change in the outcomes over time, examine time-varying associations with degree of change 
in headache frequency, and consider if any of the outcomes are especially impacted by changes in 
headache frequency. 
 
Although the associations will be conducted while treating degree of change in headache frequency as 
a continuous predictor, reporting of the effects will also be conducted using dichotomized versions of this 
predictor. Specifically, the associations will be reported for three groups of responders: non-responders 
(< 50% reduction), responders (> 50% reduction to <= 75% responders), and super-responders (> 75% 
reduction). 
 

(CCI) Committee on Clinical Investigations 
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Study Description – Part B 
CCI Form:  9-2015 
 
PI Revision Date: 11/2/2021 
 
The model estimates should be robust to missing data due to attrition. All data will be analyzed, with 
sensitivity models used to adjust the associations for additional prognostic predictors thought to be 
related to chance of attrition. If necessary, multiple imputation will be used as an additional sensitivity 
analysis. 
 
Data will be stored on password protected computers behind the BIDMC firewall or in REDCap directly.  
Analyses will be conducted by a statistician at BIDMC within the Department of Anesthesia, Critical Care 
and Pain Medicine. Statistical analyses will be conducted using SAS version 9.4 or later (SAS Institute 
Inc., Cary, NC). 
 
 
d. Data Interpretation 
 
 
If galcanezumab treatment reduced prodromes, auras, interictal hypersensitivities to light and sound, 
and the number of triggers (such as skiping meals, sleeping too little, stress or post-stres, etc.) in 
patients in which it also reduced migraine days per month by more than 75% (the super-responders), 
we will conclude that the abnormal sensitivity of the migraine brain to deviation from homeostasis 
(hypothalamus) and to external stimuli is a result of the continuous bombardment of the brain with pain 
signals that originate outside the brain. 
 
If galcanezumab treatment shrinks the thickness of the somatosensory or reduces the enhanced 
BOLD signal in the visual cortex in patients in which it also reduced migraine days per month by more 
than 75% (the super-responders), we will conclude that the abnormal structural and functional 
changes seen previously in the migraine brain are caused by the continuous bombardment of the 
brain with pain signals that originate outside the brain. 
 
If galcanezumab treatment did not reduce occurance of prodromes, auras, interictal hypersensitivities 
to light and sound, and the number of triggers (such as skiping meals, sleeping too little, stress or post-
stres, etc.), or if it did not shrink the somatosensory cortex and reversed the hyperactivity in the visual 
cortex in patients in which it reduced migraine days per month by more than 75% (the super-
responders), we will conclude that the abnormal sensitivity of the migraine brain to deviation from 
homeostasis (hypothalamus) or to external stimuli is a result of a condition that is internal to the brain 
(could be inherited or not) and that the reduction in the headache days was achieved due to the drug 
ability to block the activation of the nociceptors..   
 
If galcanezumab treatment did not eliminate aura in patients in which it reduced migraine days per 
month by more than 75% (the super-responders), we will conclude that galcanezumab acted on the 
trigeminovascular nociceptors – outside the blood brain barrier (BBB) – but not on the cortex – inside 
the bbb.   
 
If galcanezumab treatment reduced the occurrence of prodromes, auras, interictal hypersensitivity to 
light and sound in patients, and the number of triggers (such as skiping meals, sleeping too little, stress 
or post-stres, etc.) in which it did not reduce migraine days per month by more than 75% (the super-
responders), we will conclude that the abnormal sensitivity of the migraine brain to deviation from 
homeostasis (hypothalamus) and to external stimuli are independent of pain signals that continue to 
invade the brain. In such case, we will conclude that galcanezumab mechanism of action is mainly 
central, inside the CNS.  We will also conclude that the headache itself is likely to be independent of 
activation of meningeal nociceptors during migraine. 
 
If galcanezumab treatment shrinks the thickness of the somatosensory or reduces the enhanced 
BOLD signal in the visual cortex in patients in which it did not reduce migraine days per month by 
more than 75% (the super-responders), we will conclude that the abnormal structural and functional 
changes seen previously in the migraine brain are driven by mechanisms that are internal to the brain 
itself, its neurons, or reciprocal pathways. 
 
If the 3-month long galcanezumab treatment reduced incidence of prodromes, auras, and interictal 
hypersensitivities to light and sound, as well as cortical thickness and bold signal magnitide in the 
visual cortex (in responders) – and continue to reduce the monitored symptoms and triggers even 
further after 6 months treatment period, we will conclude that the brain requires a period that is longer 
than 3 month of being partially or completely ‘pain-free’ to allow neuronal plasticity to settle in and the 
brain to return to near normal functioning. If, however, the changes we monitor after 3 month remain 
similar at the 6 month post-treatment, we will conclude that a 3-month period is a sufficient time to 
allow galcanezumab to ‘heal’ the migraine brain. 

(CCI) Committee on Clinical Investigations 
Page 9 of 12 
 
Study Description – Part B 
CCI Form:  9-2015 
 
PI Revision Date: 11/2/2021 
 
This study design ensures that whatever the findings are, we will learn much about migraine 
pathophysiology and galcanezumab mechanisms of action.   
 
C. 
Subject Selection 
Potential study subjects will be provided an informed consent form (ICF) to review. Those who are interested in 
participating will provide informed consent and then be screened for eligibility (inclusion/exclusion criteria). 
Individuals screened as potential study subjects must meet all the following inclusion criteria and none of the 
following exclusion criteria. 
 
INCLUSION CRITERIA 
 
a. Between the ages of 18 and 65 years 
b. Been previously diagnosed with migraine (with or without aura), in accordance with the ICHD-3 criteria 
c. 
Experiences between 8 to 25 headache days per month (during the last 3 months), with at least 8 of them 
being migraine days during which the migraines lasted more than 4 hours if untreated 
d. Onset of migraine at age 50 years or younger 
e. Agrees to refrain from initiating or changing the type, dosage, or frequency of any prophylactic 
medications for indications other than migraine that may interfere with the study objectives (e.g., 
antidepressants, anticonvulsants, beta-adrenergic blockers, etc.) 
f. 
Participants need to have access to the internet and have their own device to complete the eDiary. 
g. Able to provide written informed consent 
 
EXCLUSION CRITERIA 
 
1. Currently on a regimen of 1 or more migraine preventative therapy 
2. Other significant pain problem (e.g., cancer pain, fibromyalgia, other head or facial pain disorder) that may 
confound the study assessments 
3. Known or suspected severe cardiac disease (e.g., symptomatic coronary artery disease, prior myocardial 
infarction, congestive heart failure) 
4. Known or suspected cerebrovascular disease (e.g., prior stroke or transient ischemic attack, symptomatic 
carotid artery disease, prior carotid endarterectomy or other vascular neck surgery) 
5. Abnormal baseline electrocardiogram (ECG) within the last year (e.g., second or third-degree heart block, 
prolonged QT interval, atrial fibrillation, atrial flutter, history of ventricular tachycardia or ventricular 
fibrillation, clinically significant premature ventricular contraction) 
6. Uncontrolled high blood pressure (systolic >160 mm HG, diastolic >100 mm Hg) after 3 measurements 
within 24 hours 
7. Known history or suspicion of secondary headache 
8. Known history or suspicion of substance abuse or addiction (within the last 5 years) 
9. Currently using marijuana (including medical marijuana) or has used marijuana (including medical 
marijuana) or cannabidiol oil within the last 1 year 
10. Currently takes simple analgesics or NSAIDs >15 days per month or triptans, ergots, or combined 
analgesics >10 days per month for headaches or other body pain 
11. Currently takes prescription opioids for headaches or body pain 
12. Undergone nerve block (occipital or other) in the head or neck within the last 3 months 
13. Received botulinum toxin or anti-CGRP-mAb injections within the last 6 months 
14. Pregnant or thinking of becoming pregnant during the study period, or of childbearing years and unwilling 
to use an accepted form of birth control 
15. Participating in any other therapeutic clinical investigation or has participated in a clinical trial in the 
preceding 30 days 
16. Belongs to a vulnerable population or has any condition such that his or her ability to provide informed 
consent, comply with the follow-up requirements, or provide self-assessments is compromised. 
17. A relative of or an employee of the Investigator or the clinical study site 
18. Psychiatric or cognitive disorder and/or behavioral problems that, in the opinion of the clinician, may 
interfere with the study 
19. Contraindication to MRI 
 

(CCI) Committee on Clinical Investigations 
Page 10 of 12 
 
Study Description – Part B 
CCI Form:  9-2015 
 
PI Revision Date: 11/2/2021 
 
  
B4. 
POSSIBLE BENEFITS 
It is not guaranteed or promised that patients will receive any benefit from being in this study. Information from 
this study may help others in the future as a result of knowledge gained from the research. 
 
B5. 
POSSIBLE RISKS AND ANALYSIS OF RISK/BENEFIT RATIO 
Migraine is common and disabling neurological disease. Migraine has been ranked seventh highest among 
specific causes of disability globally. Unfortunately, a large percentage of individuals with migraine are not 
successfully treated, and their pain and associated symptoms of photophobia, phonophobia, and nausea do not 
subside. Prior to introduction of anti-CGRP-mAb, the preventive treatment armamentarium was nonspecific and 
included anti-depressants, anti-epileptics and anti-hypertensive medications. The adherence rates with these 
classes of medications have been low (35%–50%) due to unsatisfactory efficacy and side effects. According to 
available safety and efficacy data from Phase 2 and 3 trials in episodic migraine (EM) and CM, galcanezumab 
has been shown to be safe and efficacious in preventing migraine in EM and CM patients, and reduced disability 
and functional impairment. Galcanezumab was also shown to be tolerable with low discontinuation rates in the 
clinical trials. As a potential alternative treatment for prevention of migraines, subjects recruited for study 
participation will be offered galcanezumab. Investigators believe that subjects with symptoms associated with 
migraine may benefit from monthly regimen of galcanezumab. Considering that the target migraine population is 
often refractory to standard-of-care treatment and has few low-risk options for prevention of migraines, 
investigatores believe that the potential risks of treatment with galcanezumab in this study are acceptable given 
the potential benefits of treatment. 
 
HYPERSENSITIVITY REACTIONS 
Hypersensitivity reactions such as rash, urticaria, and dyspnea have been reported with galcanezumab in clinical 
trials. If a serious or severe hypersensitivity reaction occurs, treatment with galcanezumab  will be discontinued 
and the subject will treated with an appropriate therapy. 
  
ANTICIPATED ADVERSE EVENTS 
The most common adverse reaction of galcanezumab are constipation and injection site reactions. In a phase 3, 
randomized, double-blind, placebo-controlled REGAIN study in CM and EVOLVE-2 study in EM , there were no 
clinically meaningful differences between 120 mg monthly dose of galcanezumab and placebo on any safety or 
tolerability outcomes with exception of injection site reaction, pruritus and swelling. 
 
IMMUNOGENICITY 
There is a potential for immunogenicity because galcanezumab is a therapeutic protein. In controlled studies with 
galcanezumab up to 6 months the incidence of anti-galcanezumab antibody was 4.8% (mostly neutralizing 
antibodies) . In a 12 month open-label study, up to 12.5% of patients developed anti-galcanezumab antibodies 
(mostly neutralizing antibodies).Based on limited data, presence of anti-galcanezumab antibodies was not shown 
to affect pharmacokinetics, safety or efficacy of galcanezumab. 
 
QST PROCEDURE 
The QST is designed to test a person’s pain limit, so while the participant may feel discomfort as the heat 
stimulus increases at a slow rate from 32 to 50C/89.6 to 122°F, they can stop the heat at any time and are in 
complete control of how hot the stimulus gets during the test. At this temperature range and for this duration of 
time, there is minimial risk of a burn. 
 
IMAGE-RELATED RISKS 
Metal of any kind is unsafe for the MRI procedure. Participants must remove all metal from their clothing and all 
metal objects from their person. They will not be allowed to bring any metal objects into the magnet room at any 
time. As such, the MRI is also not safe for people who have pacemakers, some ear implants, shrapnel injuries, or 
some types of metal or electric devices in their body; such persons will not be allowed to participate in the study. 
The study doctor will decide if participants who have undergone operations that have left metal in their bodies will 
be able to proceed with the scan. 
 
 

(CCI) Committee on Clinical Investigations 
Page 11 of 12 
 
Study Description – Part B 
CCI Form:  9-2015 
 
PI Revision Date: 11/2/2021 
 
People with a history of claustrophobia will also be excluded from the study, as lying in the MRI may trigger the 
phobia due to the sides and top of the scanner being very close to the participant’s face and body. 
 
REPRODUCTIVE RISKS 
Because of the effects of this study medication on the developing fetus is not known, participants cannot be 
enrolled while pregnant and must refrain from becoming pregnant during the course of the study. Participants will 
be required to take a standard urine pregnancy test to verify that they are not pregnant before receiving the first 
dose of the study medication and before each MRI session. 
 
B6. 
RECRUITMENT AND CONSENT PROCEDURES 
Recruitment 
The potential participants will be recruited largely from the investigator’s (Dr. Ashina) own patient population, as 
well as other providers in the headache clinic. Patients will either be informed about the study directly from the 
investigator in the headache clinic in the BIDMC Headache Center or if they express interest in the study they 
may be contacted by phone by the study coordinator in order to explain more about the study. 
 
ResearchMatch.org will be utilized as a recruitment tool for this protocol.  ResearchMatch.org is a national 
electronic, web-based recruitment tool that was created through the Clinical & Translational Science Awards 
Consortium in 2009 and is maintained at Vanderbilt University as an IRB-approved data repository. 
 
Consent 
Potential research subjects will be consented either before the screening visit in clinic or on the day of their 
Screening Visit. This will happen in the PI’s primary clinic location in the BIDMC Comprehensive Headache 
Center at 1 Brookline Place in Suite 406. The study will be explained by the primary investigator, or by 
another one of the qualified investigators and the Study Coordinator. Detailed information relating to the 
study drug and study procedures, along with information about the risks and benefits of participating in any 
research study and in this specific study, will be provided to the participant. The consenting process will be 
documented on a consent checklist and notes will be taken about any questions asked by the participant.  
 
Subject Protection 
There will be no coercion or undue influence placed on patients. They will be informed of the study and given 
the freedom to participate or not, and this will not influence any care provided to them. 
 
B7. 
STUDY LOCATION 
 Privacy  
 
Conversations with potential study subjects will be done in the BIDMC Comprehensive Headache Center at 1 
Brookline Place in Suite 406. Conversations over the phone will be done in offices within the hospital so that 
sensitive information cannot be overheard by anyone other than study staff. 
 
The study will be performed in standard patient rooms in the BIDMC Comprehensive Headache Center at 1 
Brookline Place in Suite 406. This location provides protection against study subjects being witnessed and 
conversations overheard by anyone other than study staff.  
 
 Physical Setting 
 
The proposed study will take place in the BIDMC Comprehensive Headache Center at 1 Brookline Place in 
Suite 406 as outpatient visits. The clinic visits will occur in the BIDMC Comprehensive Headache Center at 1 
Brookline Place in Suite 406 and the MRI visits will occur at the BIDMC MRI center in the Ansin Building of 
330 Brookline Avenue. Pregnancy testing will occur in the BIDMC MRI center. 
 
B8. 
DATA SECURITY 
 
We will store electronic data in a password-protected directory on a secure server behind the BIDMC firewall. 
All paper records will be stored in a locked room that will be accessed only by members of the study team. Only 
the study team will have access to identifiable information. 
 

(CCI) Committee on Clinical Investigations 
Page 12 of 12 
 
Study Description – Part B 
CCI Form:  9-2015 
 
PI Revision Date: 11/2/2021 
 
 
B9 
Multi-Site Studies 
 
Is the BIDMC the coordinating site?  
 Yes    
 No  
 
Is the BIDMC PI the lead investigator of the multi-site study?   
 Yes    
 No  
 
 
B10 
Dissemination of Research Results 
 
Subjects will be thanked for their participation at the completion of their study and follow-up procedures.  Upon 
request, the sponsor will provide copies of publications that result from this project. Publications will also be 
printed in publicly available journals. 
 
 
References 
 
Lipton RB, Serrano D, Pavlovic JM, Manack AN, Reed ML, Turkel CC, Buse DC. 
Improving the classification of migraine subtypes: an empirical approach based on 
factor mixture models in the American Migraine Prevalence and Prevention (AMPP) 
Study. Headache. 2014 May;54(5):830-49.  
 
Torres-Ferrús M, Quintana M, Fernandez-Morales J, Alvarez-Sabin J, Pozo-Rosich 
P. When does chronic migraine strike? A clinical comparison of migraine according 
to the headache days suffered per month. Cephalalgia. 2017 Feb;37(2):104-113.