A Phase IIa Randomized, Placebo-controlled Clinical Trial to Evaluate the Efficacy and Safety of Bimatoprost in the Treatment of Migraine
Phase: PHASE2
Conditions: Migraine Disorders, Headache Disorders
Sponsor: Manistee Partners

Asentral, Inc. Institutional Review Board Approved – January 2, 2018 
 
 
Manistee Partners 
 
Confidential 
 
Manistee Partners: 
Title:   CLINICAL STUDY PROTOCOL 
Protocol Number:  17-MAN-001 
Version Number: 1.1 
Effective:12/21/17 
Page: 1 of 13 
A Phase II randomized, placebo-controlled clinical trial to 
evaluate the efficacy and safety of bimatoprost in the 
treatment of episodic migraine. 
Protocol #:  17-MAN-001 
Date:  December 21, 2017  
Clinical phase:  Phase II 
Sponsor contact information:  
 
Manistee Partners, LLC 
 
Robert L. Bratzler, PhD, Managing partner 
 
84 Barnes Hill Road 
 
Concord, MA 01742 
 
rbratzler@gmail.com 
 
Phone:  1-617- 538-7105 
 
Scientific/Medical Monitor: 
Martha McGuire 
104 Pokonoket Avenue 
Sudbury, MA 01776 
Phone:  1-978-579-0069 
martha.mcguire@yahoo.com  
 
Principal Investigator:   
Herbert G. Markley, MD, FAAN 
Director, New England Regional Headache Center 
85 Prescott St, Suite #101 
Worcester, MA  01605 
Phone:  1-508-890-5633 
Fax: 1- 508-890-1125 

Asentral, Inc. Institutional Review Board Approved – January 2, 2018 
 
 
Manistee Partners 
 
Confidential 
 
Manistee Partners: 
Title:   CLINICAL STUDY PROTOCOL 
Protocol Number:  17-MAN-001 
Version Number: 1.1 
Effective:12/21/17 
Page: 2 of 13 
Document History: 
Version 
Date 
Replaces 
Description of Changes 
1.1 
12/21/2017 
1.0 
Relaxation of exclusion criteria to permit 
enrollment of subjects currently taking 
antidepressants 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Asentral, Inc. Institutional Review Board Approved – January 2, 2018 
 
 
Manistee Partners 
 
Confidential 
 
Manistee Partners: 
Title:   CLINICAL STUDY PROTOCOL 
Protocol Number:  17-MAN-001 
Version Number: 1.1 
Effective:12/21/17 
Page: 3 of 13 
Protocol Signature Page  
Approvals:   
 
______________________________________________________ 
 
_____________ 
Robert L. Bratzler, PhD, Managing Partner, Manistee Partners, LLC 
 
 
Date 
 
 
 
______________________________________________________ 
 
_____________ 
B. Thomas Hutchinson, M.D., Member, Manistee Partners, LLC  
 
Date 
 
 
______________________________________________________ 
 
_____________ 
Frederick C. Ryckman, M.D., Member, Manistee Partners, LLC  
 
Date 
 
 
______________________________________________________ 
 
______________ 
Bradford J. Shingleton, M.D., Member, Manistee Partners, LLC  
 
Date 
 
 
______________________________________________________ 
 
______________ 
Martin Wand, M.D., Member, Manistee Partners, LLC  
 
 
Date 

Asentral, Inc. Institutional Review Board Approved – January 2, 2018 
 
 
Manistee Partners 
 
Confidential 
 
Manistee Partners: 
Title:   CLINICAL STUDY PROTOCOL 
Protocol Number:  17-MAN-001 
Version Number: 1.1 
Effective:12/21/17 
Page: 4 of 13 
Investigators protocol signature page: 
I confirm that I have read this protocol, I understand it and I will work according to this protocol 
and the ethical principles stated in the Code of Federal Regulations (CFR), title 45, part 46, as well 
as ICH E6, GCP guidelines, and applicable local and state laws and regulations of the study site for 
which I am responsible, whichever provides the greater protection of the individual.  I will abide by 
the publication rules set forth in my agreement with Manistee Partners, LLC.  I will accept the 
monitor’s inspection and overseeing of the study.  I will promptly submit the protocol to the 
applicable Institutional Review Board for approval. 
 
____________________________________________  
 
__________________ 
Herbert G. Markley, M.D. FAAN  
 
 
 
 
 
Date 
Director, New England Regional Headache Center 
85 Prescott Street, Suite 101 
Worcester, MA 01605 

Asentral, Inc. Institutional Review Board Approved – January 2, 2018 
 
 
Manistee Partners 
 
Confidential 
 
Manistee Partners: 
Title:   CLINICAL STUDY PROTOCOL 
Protocol Number:  17-MAN-001 
Version Number: 1.1 
Effective:12/21/17 
Page: 5 of 13 
Acronyms and Definitions: 
NERHC – New England Regional Headache Center 

Asentral, Inc. Institutional Review Board Approved – January 2, 2018 
 
 
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Confidential 
 
Manistee Partners: 
Title:   CLINICAL STUDY PROTOCOL 
Protocol Number:  17-MAN-001 
Version Number: 1.1 
Effective:12/21/17 
Page: 6 of 13 
1. PURPOSE OF STUDY AND BACKGROUND 
 
a. Purpose:  To assess the efficacy and safety of a topical prostaglandin F2 alpha analog 
(bimatoprost) applied to the fingernail bed in reducing frequency, severity, duration 
and disability of migraine headaches. 
 
b. Background:  This study is important because it is estimated that 36 million people in 
the United States suffer from migraine headaches and this number may reach 1.2 
billion worldwide.  The global migraine evaluation survey found a 12% migraine 
prevalence worldwide and many patients suffer without adequate short-term 
treatment and/or long-term control (1).  The annual value of loss productivity from 
migraine headaches in the United States is $13 billion (1)..   
Prostaglandins are created from arachidonic acid and are part of the body’s 
inflammatory response.  They participate in a wide range of functions, such as 
contraction and relaxation of small smooth muscles, dilation and constriction of 
blood vessels, control of blood pressure and modulation of inflammation.  
Intravenous infusion of vasodilating prostaglandins (E2, E3, I2 and D2) has been 
shown to induce headaches, whereas non-vasodilating prostaglandins (F2 alpha) are 
not associated with headaches (2).   
Hall, et al. (3) observed that treatment with topical prostaglandin F2 alpha analogs 
(applied either to the eye or fingernail bed) significantly reduced the frequency, 
severity and duration of headaches in migraine sufferers, as well as the migraine 
disability assessment score (MIDAS). 
 
c. Primary endpoint of the study:  Does topical bimatoprost (a prostaglandin F2 alpha 
agonist) applied to the fingernail beds reduce the number of headache days per 
month in episodic migraineurs? 
 
d. Secondary endpoints:  Does topical bimatoprost applied to the fingernail beds of 
episodic migraineurs (a) reduce severity of migraine headaches; (b) reduce duration 
of headaches; (c) improve the quality of life as measured by the MIDAS score and 
headache intensity assessment.   
 
2. STUDY DESIGN 
Study drug:  Topical bimatoprost 0.03% solution is a prostaglandin F2 alpha analog.  It is FDA 
approved for topical application to the eye in the treatment of glaucoma.  Prostaglandins, 
including bimatoprost, have been used to topically treat glaucoma for 30+ years.  When applied 
to the eye, bimatoprost is well tolerated and results in decreased intraocular pressure.  Eye 
drop application can be associated with alteration in pigmentation of pigmented tissues and 

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Manistee Partners: 
Title:   CLINICAL STUDY PROTOCOL 
Protocol Number:  17-MAN-001 
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Effective:12/21/17 
Page: 7 of 13 
eyelash growth.  It is rarely associated with intraocular inflammation, macular edema, bacterial 
keratitis, conjunctival hyperemia, conjunctival hemorrhage, eye irritation, eye pain, itchy eye, 
erythema of the eyelid, eyelid itchiness, instillation site irritation, punctate keratitis, visual 
blurring and visual acuity reduction.  Eye drop application has also been associated with 
periorbital and lid changes including deepening of the eyelid sulcus (4).  Topical application to 
the fingernail bed may be associated with a slight increase in fingernail growth.   
 
Headaches (but not the more severed and debilitating frequent migraine headaches) are 
reported as a potential systemic adverse side effect in 1-5% of patient’s taking topical 
bimatoprost ophthalmic solution administered to the eye (4).  Headaches may rarely occur with 
many medications.  However, the greater than 80% positive response rate with reduction in 
headache frequency and severity documented in the study by Hall, et al. (3) using topical 
bimatoprost to the fingernails represents a significantly greater benefit without meaningful 
added risk to study patients.  
a. Study treatment group:  This will be a 16-week double-blind, randomized, placebo-
controlled parallel group trial of prophylactic bimatoprost in up to 80 patients with 
episodic migraine.  There will be a 1:1 randomization across the two groups, 
bimatoprost and placebo.  Randomization will be done using a computer random 
number generator.  Randomization assessment of the subjects will be done blind to 
treatment assignment.  Based on a review of placebo-control trials of migraine, we 
assume a 20% difference in changes from baseline in monthly headache frequency 
for a calculation of sample size.  With a power of [80%, significance of this level of 
5% (one-sided) and an effect size of 0.8 (large), the sample size requirement is 30 in 
each group.    
b. Treatment regimen:  Bimatoprost 0.03% solution and a placebo will be placed in 
ophthalmic bottles.  Treatment and placebo groups will place one drop 
(approximately 25 µl) once daily on the nail bed (lunula) of each of four fingers on 
the non-dominant hand.  The drops will be allowed to air dry.  No nail polish is to be 
used during the trial.  This compares to one drop (approximately 25 µl) of 0.03% 
solution being FDA- approved for administration once daily into each of two eyes for 
treatment of glaucoma. 
c. Study visits:  The study will consist of four visits for each patient: a screening visit 
(V1), week -4; randomization visit (V2), week 0; a compliance visit (V3), week 6; an 
end-point visit (V4), week 12.  A compliance phone call assessment will be made to 
each participant at week 3 and week 9.   
d. Study duration:  The study will continue for 16 weeks and each participant will be 
expected to participate in the full extent of the study.  
 
 
 

Asentral, Inc. Institutional Review Board Approved – January 2, 2018 
 
 
Manistee Partners 
 
Confidential 
 
Manistee Partners: 
Title:   CLINICAL STUDY PROTOCOL 
Protocol Number:  17-MAN-001 
Version Number: 1.1 
Effective:12/21/17 
Page: 8 of 13 
3. CRITERIA FOR SUBJECT SELECTION 
a. Number of subjects:  Eighty subjects are expected to participate. 
b. Gender of subjects:  Male and female patients will be admitted to the study.  There 
will be no gender restriction, except pregnant and lactating females will be excluded.   
c. Age of subjects:  The age range will be 18-65 years.  Migraine manifestation and 
treatment is more complex and variable in children and adolescents.  General 
medical issues and transportation availability can become problematic for people 
over age 65. Therefore, the age range of 18-65 has been selected.   
d. Racial and ethnical profile:  There are no restrictions based on race or ethnic origin.   
e. Inclusion criteria:  Inclusion for study will be diagnosis of episodic migraines based 
on International Classification of Headache Disorders (ICHD) II criteria and 
experiencing headaches for 4-14 days per month, the internationally accepted 
definition of “episodic migraine” patients.  All our patients will be screened to make 
sure they do not have other medical conditions that are causing their migraines.  The 
subjects in the study will already be taking medications as recommended by their 
primary physician.  Patients will be permitted to use stable doses of up to three 
different standard migraine preventive drugs for at least three months before study 
onset.  Patients will be allowed to treat acute migraine headaches as usual and they 
must show compliance (at least 80%) with a headache diary during the four-week 
run-in phase.   
f. Exclusion criteria:  Exclusion criteria are significant liver or renal dysfunction, on 
treatment for inflammatory bowel disease, medication over-use for headaches 
according to the ICHD II criteria, use of antipsychotics in the past month, recent (in 
the past six months) history of alcohol or drug abuse, allergy to bimatoprost and its 
compounds, severe comorbid psychiatric illness, severe infection, malignancy, 
severe cardiovascular disease, neurodegenerative disorders, pregnancy and 
lactation, and sexually active women of child bearing age who do not use any 
method of contraception.   
g. Vulnerable subjects will not be included 
h. Consent:  All subjects will read and sign the appropriate form approved by the 
Asentral Review Board (IRB).  This study will be conducted in accordance with the 
principles of Good Clinical Practice and with the US Food and Drug Administration 
(FDA) guidelines for safety monitoring, as well as the last revisions of the Declaration 
of Helsinki.  The study will also be registered in www.clinicaltrials.gov.   
i. Subject Identification Number:  Before subjects begin participation in any study-
specific activities/procedures, Manistee requires a copy of subject information. Each 
subject who enters into the screening period for the study shall sign and date the 
informed consent and receive a unique, randomly assigned subject identification 
number. The subject identification number will be used to identify the subject 

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Manistee Partners: 
Title:   CLINICAL STUDY PROTOCOL 
Protocol Number:  17-MAN-001 
Version Number: 1.1 
Effective:12/21/17 
Page: 9 of 13 
throughout the clinical study and will be used on all study documentation related to 
that subject. 
A subject is considered enrolled when the Principle Investigator or Sub-Investigator 
decides that the subject has met all eligibility criteria and is randomized. The 
Principle Investigator or Sub-Investigator is to document this decision date and enter 
it in the subject's medical record and on the enrollment case report form (CRF). 
 
The subject identification number will remain constant throughout the entire clinical 
study; it will not be changed after initial assignment, including if a subject is 
rescreened. This number will not include any identifiers for the subject. 
 
4. METHODS AND PROCEDURES 
a. Study Drug:  The study drug will be sourced, labeled, and packaged in 3 ml sterile 
ophthalmic bottles by Boulevard Compounding Pharmacy, a licensed pharmacy, 
located in Worcester, Massachusetts.  It will be stored there at room temperature in 
a locked cabinet until needed for distribution at the clinical test site.  The pharmacy 
will label each bottle with a unique number, assigned to a unique subject 
identification number, according to the Sponsor’s computer-generated 
randomization code.  The study site will be responsible for recording the study drug 
code on each subject’s case report form. 
b. Study Visits and Duration:  The study will be a 16-week double-blind, randomized 
placebo-control parallel-group trial of prophylactic bimatoprost in patients with 
migraine.  The study will consist of a 4-week baseline after which the patients will be 
treated for 12 weeks.  The patients will come in four visits: a screening visit (V1), 
week -4; a randomization visit (V2), week 0; a compliance visit (V3), week 6; an end-
treatment visit (V4), week 12.  Compliance phone call assessments will be made to 
each participant at week 3 and week 9.   
i. The screening visit (V1) will consist of informed consent, eligibility and 
exclusion criteria, medical and psychiatric history, concomitant medications, 
height, weight, vital signs, physical and neurological examination, review of 
daily diary and dispensing of diaries.  Urine tests for drug use, blood sampling 
for blood chemistries and EKG will be performed.   
ii. The randomization visit (V2) consists of diary collection, diary review and, 
where necessary, correction by the subject, health status changes, 
concomitant medications, MIDAS questionnaire, dispensing of daily diaries 
and study medication.  At the end of the randomization visit, but before 
medication is dispensed, it will be established that the subject meets 
eligibility and exclusion criteria.   

Asentral, Inc. Institutional Review Board Approved – January 2, 2018 
 
 
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Confidential 
 
Manistee Partners: 
Title:   CLINICAL STUDY PROTOCOL 
Protocol Number:  17-MAN-001 
Version Number: 1.1 
Effective:12/21/17 
Page: 10 of 13 
iii. The compliance visit (V3) consists of diary collection and review and, when 
necessary, correction by the subject, study medication accountability, 
medication administration compliance, health status changes, adverse 
occurrences, concomitant medications and dispensing of study medication as 
necessary.    
iv. The end treatment (V4) consists of diary and study medication collection, 
diary review and, where necessary, correction by the subject, study 
medication accountability, medication administration compliance, health 
status changes, adverse event occurrences, concomitant medications, and 
MIDAS questionnaire.   
v. The week 3 and week 9 phone calls will be made to each participant to 
confirm compliance with medication usage, diary completion, health status 
changes, adverse medical events, and concomitant medications will be 
addressed.   
c.  Data analysis and data monitoring:  Patients will be instructed to record in a diary 
the number of headache attacks per day and the headache intensity, duration, 
disability level, associated symptoms and medications taken. The headache diary will 
be filled out every day of the month, even on days when the patient has no 
headache (see diary form).   
 
The Migraine Disability Assessment Scale (MIDAS) is a five-item instrument 
developed to measure migraine related disability and functional consequences.  It is 
divided into four categories based on the score of: 0-5, minimal disability; 6-10, mild 
disability; 11-20, moderate disability; greater than 20; severe disability.  Reliability 
and validity of MIDAS questionnaires have been well established  
d. Primary outcome:  The primary outcome measures will be the difference in the 
average change from the 4-week baseline period in the number of migraine 
headache days with moderate or severe intensity compared to weeks 9-12 between 
the two groups. 
A migraine headache day is defined as any calendar day on which a headache which 
meets criteria A, B and C listed below occurs.  
A. Headache has at least two of the following: 
i. Unilateral location 
ii. Pulsating quality 
iii. Moderate or severe pain intensity 
iv. Aggravated by or causing avoidance of routine physical activity (e. g., 
walking or climbing stairs) 
B. At least one of the following: 
i. Nausea and/or vomiting 
ii. Photophobia and phonophobia 

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Manistee Partners: 
Title:   CLINICAL STUDY PROTOCOL 
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iii. Typical aura (i. e., visual, sensory, or speech/language) accompanying or 
iv. Within 60 minutes before headache begins 
C. Duration of headache lasting 2 hours or longer on a calendar day unless an 
acute, migraine-specific medication (i. e., triptan or ergot derivative) was 
used after the start of the headache, in which case no minimum duration to 
be specified. 
e. Secondary outcomes:  Secondary outcome measures will be:   
i. Percentage reduction in the average weekly number of migraine headaches 
comparing baseline to weeks 9-12. 
ii. Change in the MIDAS score comparing baseline to weeks 9-12. 
iii. Change in severity of headaches comparing baseline to weeks 9-12. 
iv. Change in duration of headaches comparing baseline to weeks 9-12 
f. Data recording:  All data will be collected in the form of the written diaries and case 
report forms.  No data will be collected electronically.  All original data documents 
will be photocopied and provided to the Sponsor for data analysis.  At the conclusion 
of the study all data documents will be scanned and converted into electronic files 
for secure archival storage; all the original paper documents will be stored in a 
locked cabinet. 
g. Data review and analysis:  All study data will remain blinded to both the patients and 
all investigators at the NERHC.  Manistee Partners will have access to unblinded data 
throughout the trial as it is accrued.  Interim data analysis will be undertaken at a 
midpoint of the trial. 
h. Data storage and confidentiality:  All data will be stored on a secure server in a 
secure file for a period of 5 years.  
i. Transition from research participation:  At the termination of the study (V4), each 
subject will be returned to their usual care.  There will be no compassionate use 
extension or rollover of placebo group to treatment group.   
 
5. RISK BENEFIT ASSESSMENT 
a. Risk category:  There is minimal risk associated with this study.   
b. Potential risks:  The most likely potential risk to the study is that participants may 
notice a slightly more rapid rate of fingernail growth.  There are no other anticipated 
side effects.   
c. Protection against risks:  The study, with V3 and V4 visits and phone call assessment 
at three weeks and nine weeks, will allow for assessment of adverse occurrences or 
health status changes.   

Asentral, Inc. Institutional Review Board Approved – January 2, 2018 
 
 
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Confidential 
 
Manistee Partners: 
Title:   CLINICAL STUDY PROTOCOL 
Protocol Number:  17-MAN-001 
Version Number: 1.1 
Effective:12/21/17 
Page: 12 of 13 
d. Potential benefits for subjects:  Potential benefits include reduction in migraine 
frequency, severity and duration of headaches.   
e. Alternatives to participation:  All patients will continue to use their program of 
alternative therapies and course of action for treatment of migraine headaches.  If a 
subject elect not to participate in the study, their primary care practitioner and/or 
neurologist can continue to prescribe accepted methods of treatment for migraine 
headaches.   
f. Patient entry and withdrawal procedures:   Once a Subject enters the clinical trial 
they can withdraw at any time. 
 
6. SUBJECT IDENTIFICATION, RECRUITMENT, AND CONSENT 
a. Method of subject identification and recruitment: Subjects will be identified from 
the data base and files of NERHC, Inc. Data Mining will be performed. 
b. Subject capacity:  Only those patients with the capacity to give informed consent will 
be included in this study.   
c. Debriefing procedures:  No psychological information will be withheld from the 
subjects.   
d. Consent forms:  See attached. 
e. Documentation of consent:  The Principal investigator is responsible for ensuring 
that valid consent is obtained and documented for all subjects.   
i. Process: NERHC, Inc. will provide each subject a consent to review in a 
private location. They will be asked to write down any questions he/she must 
review with study staff. Any questions study staff is unable to answer the PI 
will provide the information to the subject. Once all questions are answered, 
the subject will sign the consent to participate in the clinical trial and 
witnessed by the person obtaining the consent. No study procedures will be 
performed prior to the consent being obtained.  
f. Cost to subject:  No charge or expenses associated with the study will be accrued to 
the subjects.  The sponsor will pay for the study drug, performance of the clinical 
trial and statistical analysis.   
g. Payment for participation:  Each subject will who completes the full study will 
receive up to a total of $450.00 if they complete this study. If they do not complete 
the study, for any reason, they will be paid for the study visits they do complete 
according to the following schedule: $150.00 for Visits 1 and 4, $75.00 for Visits 2 
and 3.  They will be paid at the time their participation in the study ends 
 
 

Asentral, Inc. Institutional Review Board Approved – January 2, 2018 
 
 
Manistee Partners 
 
Confidential 
 
Manistee Partners: 
Title:   CLINICAL STUDY PROTOCOL 
Protocol Number:  17-MAN-001 
Version Number: 1.1 
Effective:12/21/17 
Page: 13 of 13 
7. ETHICS 
The study will adhere to the requirements of the Asentral Review Board (IRB), ICH GCB 
guidelines and the Declaration of Helsinki and the study will be HIPPA compliant.    
 
8. STUDY CLOSURE  
The study will close once last subject is completed. 
 
9. PUBLICATION 
Presentations at medical, neurology and ophthalmology symposia are anticipated along 
with possible submission for publication in peer and non-peer reviewed journals.   
 
10. REFERENCES 
1. Marcher DB, et al., The Headache Management Trial:  A Randomized Study of 
Coordinated Care.  Headache.  2008 Oct; 48(9): 1294-310. 
2. Antonova M.  Prostaglandins and Prostaglandin Receptor Antagonism in Migraine.  Dan 
Med J. 60 (5), B4635. 5 2013. 
3. Hall LB et al.  The Effect of Topical Prostaglandins on Migraine Headaches.  Poster 
Presentation at the Association for Research in Vision and Ophthalmology Annual 
Meeting, May 2017. 
4. Package Insert for Lumigan 0.03%.  Allergan, Inc.