An Open Label, Single Arm, Multicenter Study Assessing the Efficacy and Safety of Nerivio, a Remote Electrical Neuromodulation Device, for Acute Treatment of Migraine in People With Chronic Migraine
Phase: NA
Conditions: Chronic Migraine
Sponsor: Theranica

 
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CLINICAL INVESTIGATION PLAN  
STUDY TITLE:  
An open label, single arm, multicenter study assessing the efficacy and 
safety of Nerivio, a remote electrical neuromodulation device, for acute 
treatment of migraine in people with chronic migraine   
 
PROTOCOL NUMBER: 
 
TCH006 
CLINICALTRIAL.GOV 
 
NCT04194008 
REVISION: 
 
 
1.0 
RELEASE DATE:  
 
01/September/2019 
DEVICE: 
Nerivio, a Neuromodulator device for the acute treatment of 
migraine 
INVESTIGATOR:    
_____________________ 
SPONSOR:  
 
 
Theranica Bio-Electronics Ltd 
4 Ha-Omanut st, Netanya, Israel 
CONTACT DETAILS: 
  
Dagan Harris, VP Clinical & Regulatory 
Tel: +972.72.390.9758 
Fax: + 972.72.390.9762 
Mobile: +972-0542220121 
EMAIL: daganh@theranica.com 
 
 
APPROVED BY: 
POSITION: 
DATE: (DDMMYY) 
SIGNATURE: 
 
___________ 
____________ 
  _ _ /_ _ /_ _ 
 
______________ 
___________  
____________ 
  _ _ /_ _ /_ _  
______________ 
 
 
 
 

 
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The sponsor of this study, Theranica Bioelectronics Ltd, manufacturer of the Nerivio 
device for the acute treatment of migraine, states the following: 
a) 
This study will be conducted in compliance with the protocol (after being 
approved by the local IRB/EC and, if required, by the relevant health care 
agencies), US 21 CFR Parts 50, 54, 56 and 812, 45 CFR Part 46, national laws and 
regulation concerning clinical trials, the Good Clinical Practices (GCP) set forth in 
ISO 14155 (2011) standard and the ethical principles that have their origin in the 
Declaration of Helsinki. 
b) 
The Protocol, Informed Consent Form (ICF), patient's information material, and 
advertising material (if applicable) will be submitted and approved by the ethics 
and regulatory authorities, and any request by the IRB/EC or regulatory agencies 
will be complied with. Approval will be obtained prior to enrollment of any 
patients. 
c) 
Adequate insurance policy will be held valid for the entire study duration as well 
as for the discovery period required per local regulation.  
 
 

 
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Protocol Signature Page for Investigator 
The signing of this Clinical Investigation Plan (CIP) by the Principal Investigator signifies that 
the contents have been laid down in full agreement and that the study will be conducted per 
this CIP, its amendments, the clinical trial agreement and the applicable regulatory 
requirements.  
 
The Principal Investigator confirms that written Institutional Review Board (IRB) Ethics 
Committee approval for the amended CIP will be obtained prior to commencing with data 
collection. This approval must be in the Principal Investigator’s name and a copy sent to 
Theranica Bioelectronics. Additionally, the Principal Investigator must sign the declaration 
below: 
 
I will provide copies of this CIP and all pertinent information to the study personnel under 
my supervision. I will discuss this material with them and ensure they are fully informed 
regarding the conduct of the Study. 
 
 
 
 
 
Investigator’s Signature 
 
Date 
 
 
 
 
 
 
 
 
 
Investigator’s Printed Name 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Site Name 
 
Site # 
 
 
 

 
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Table of contents 
1. 
Synopsis ................................................................................................................................... 7 
2. 
Background ............................................................................................................................ 11 
3. 
Identification and description of the device information .......................................................... 12 
3.1. 
Intended use ........................................................................................................................... 12 
3.2. 
Device description .................................................................................................................. 12 
3.3. 
The application ....................................................................................................................... 13 
3.4. 
Operational context ................................................................................................................ 14 
3.5. 
Principle of operation .............................................................................................................. 15 
3.6. 
Output parameters.................................................................................................................. 16 
3.7. 
Instructions for use ................................................................................................................. 17 
3.8. 
Identification of the medical device ......................................................................................... 17 
3.9. 
Training .................................................................................................................................. 17 
4. 
Preliminary investigations and justification for the study design ............................................. 17 
4.1. 
Previous pre-clinical experience ............................................................................................. 17 
4.2. 
Previous clinical experience ................................................................................................... 18 
4.2.1 
Pilot study (NCT02453399).................................................................................................... 18 
4.2.2 
TCH-003 Pivotal study (NCT03361423) ................................................................................ 19 
4.3. 
Clinical investigation risks and benefits .................................................................................. 24 
4.3.1. 
Anticipated benefits to participants ......................................................................................... 24 
4.3.2. 
Risks and adverse effects ...................................................................................................... 24 
4.3.3. 
Risk-benefit balance ............................................................................................................... 25 
5. 
Objectives & hypotheses ........................................................................................................ 25 
5.1. 
Study objectives ..................................................................................................................... 25 
5.2. 
Study hypothesis .................................................................................................................... 25 
6. 
Study design ........................................................................................................................... 25 
6.1. 
Participants ............................................................................................................................. 25 
6.1.1. 
Inclusion criteria...................................................................................................................... 26 
6.1.2. 
Exclusion criteria .................................................................................................................... 26 
6.1.3. 
Contraindications .................................................................................................................... 26 
6.1.4. 
Withdrawal/discontinuation ..................................................................................................... 27 
6.2. 
Stimulation program ............................................................................................................... 27 
6.3. 
Procedures ............................................................................................................................. 27 
6.3.1
.
 
Study duration ........................................................................................................................ 30 
6.4. 
Study endpoints ...................................................................................................................... 30 
6.4.1. 
Primary efficacy endpoint ....................................................................................................... 30 

 
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6.4.2. 
Secondary efficacy endpoints ................................................................................................. 31 
6.4.3. 
Exploratory efficacy endpoints ................................................................................................ 31 
6.5
.
 
Methods and timing of assessing and analysing variables ..................................................... 32 
6.6. 
Data management .................................................................................................................. 32 
7. 
Statistical Considerations ....................................................................................................... 33 
7.1. 
Study design and aim ............................................................................................................. 33 
7.2. 
Endpoints ............................................................................................................................... 33 
7.2.1. 
Primary efficacy endpoint ....................................................................................................... 33 
7.2.2. 
Secondary efficacy endpoints ................................................................................................. 33 
7.2.3. 
Exploratory efficacy endpoints ................................................................................................ 34 
7.3. 
Sample size ............................................................................................................................ 35 
7.4. 
Analysis sets .......................................................................................................................... 35 
7.5. 
Statistical analysis .................................................................................................................. 35 
7.5.1. 
General considerations ........................................................................................................... 35 
7.5.2. 
Demographic and other baseline variables ............................................................................ 36 
7.5.3. 
Efficacy analysis ..................................................................................................................... 36 
7.5.4. 
Safety analysis ....................................................................................................................... 36 
7.5.5. 
Treatment by sites interaction ................................................................................................ 37 
7.5.6. 
Handling of missing data ........................................................................................................ 37 
8. 
Data management .................................................................................................................. 37 
8.1 
Data capture ............................................................................................................... 37 
8.1.1 
Direct data entry .......................................................................................................... 38 
8.2 
Data quality assurance ................................................................................................. 38 
8.3 
Electronic signatures ................................................................................................... 38 
8.4 
Verification, validation and securing of electronic data capture system .............................. 38 
8.5 
Records and data retention .......................................................................................... 38 
8.6 
Other aspects of clinical quality assurance ..................................................................... 39 
9. 
Amendments and deviations from the protocol ...................................................................... 39 
9.1. 
Protocol amendments ............................................................................................................. 39 
9.2. 
Protocol deviations ................................................................................................................. 40 
9.2.1 
Procedures for recording, reporting and analyzing protocol deviations ................................. 40 
9.3 
Notification requirement and timelines ................................................................................... 41 
10. 
Device accountability .............................................................................................................. 41 
11. 
Informed consent process ...................................................................................................... 42 
12. 
Adverse events ....................................................................................................................... 42 
12.1. 
Characteristics of AEs ............................................................................................................ 42 
12.2. 
Reporting of AEs and SAEs ................................................................................................... 43 

 
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12.3. 
Anticipated device-related AEs ............................................................................................... 44 
12.4. 
Device malfunction ................................................................................................................. 44 
13. 
Early termination .................................................................................................................... 45 
13.1 
Criteria and procedures ......................................................................................................... 45 
13.2 
Requirements for patient follow-up in case of withdrawal ...................................................... 45 
14. 
Publication policy .................................................................................................................... 45 
15. 
Patient confidentiality & data protection .................................................................................. 45 
16. 
Guidelines and applicable documents .................................................................................... 45 
17. 
Reference ............................................................................................................................... 46 
 
 
 

 
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1. 
Synopsis 
 
Title 
An open label, single arm, multicenter study assessing the efficacy and safety of 
Nerivio, a remote electrical neuromodulation device, for acute treatment of 
migraine in people with chronic migraine  
Sponsor 
Theranica Bio-Electronics Ltd. 4 Ha-Omanut St., Netanya, Israel 
Investigational 
Device 
Nerivio is an FDA-authorized remote electrical neuromodulation (REN) device for 
the acute treatment of migraine with or without aura in patients 18 years old or 
above who do not have chronic migraine. The device delivers transcutaneous 
electrical stimulation to the upper arm to induce conditioned pain modulation 
(CPM) that activates a descending endogenous analgesic mechanism. The 
treatment is self-administered and controlled by a smartphone application. A 
recent pivotal study in adults with episodic migraine demonstrated that the device 
provides an effective acute migraine treatment with a favorable safety and 
tolerability profile. 
Objectives 
To evaluate the efficacy and safety of Nerivio for the acute treatment of migraine 
in people with chronic migraine 
Patient 
Population 
Adults 18-75 years old meeting the International Headache Society criteria 
(ICDH-3) for chronic migraine  
Sample size 
Up to 150 participants.  
Inclusion criteria 
1. Participants aged 18-75 years old. 
2. Participants meeting the ICHD-3 diagnostic criteria for chronic migraine  
3. Participants experiencing between 15 to 23 headache days per month, with at 
least 8 headache days (per month) with migraine phenotype presentation 
4. Participants have personal access to a smartphone 
5. Participants must be able and willing to comply with the protocol 
6. Participants must be able and willing to provide written informed consent 
Exclusion criteria 
1. Participants with an active implanted electrical and/or neurostimulator device 
(e.g. cardiac pacemaker, cochlear implant). 
2. Participants with congestive heart failure (CHF), severe cardiac or 
cerebrovascular disease. 
3. Participants with uncontrolled epilepsy. 
4. Lack of efficacy, after an adequate therapeutic trial, of at least two migraine 
specific acute medications. 
5. Change in migraine preventive medications (type or dose) in the last two 
months prior to recruitment and/or during the study  
6. Pregnant, trying to get pregnant or breastfeeding female participants 
7. Subjects participating in any other interventional clinical study. 
8. Participants without basic cognitive and/or motor skills needed to operate a 
smartphone 
9. Participants with other significant pain, medical or psychological problems that 
in the opinion of the investigator may confound the study assessments  
10. Participants who have previous experience with the device 

 
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Study Design 
A prospective, single arm, open-label, multicenter trial that will be conducted in 
three phases:  
Phase I - Run-in:  
Eligible participants will be trained to use a smartphone migraine diary application. 
During the 4 weeks of this phase, participants will be instructed to report all their 
migraines and headaches at onset. For each episode, participants will be 
instructed to report headache level, presence/absence of associated symptoms, 
and use of medications at baseline, at onset, 2 hours post report and 24 hours 
post report. Participants who comply with the migraine diary reporting will continue 
to the treatment phase.  
Phase II – Treatment:  
A 4-week treatment phase in which participants will be asked to treat their migraine 
headaches with the Nerivio device and to avoid taking medications within 2 hours 
post-treatment. The treatments with the device should be performed within 60 
minutes of the onset of migraine or headache. Participants will be asked to report 
their headache level, presence/absence of associated symptoms, and use of 
medication using the smartphone application at baseline, 2 hours post-treatment 
and 24 hours post-treatment. Participants who do not achieve satisfactory relief at 
2 hours post-treatment may treat again with the device. The first use of the device 
in this phase will be considered a training treatment and will not be included in the 
efficacy analyses. The first treatment of a qualifying migraine headache (see 
below) after the training treatment is considered the test treatment and will be used 
for all efficacy assessments. 
Phase III - Follow-up: 
Participants who complete the treatment phase will be offered to participate in an 
8-week follow-up phase in which they will incorporate the Nerivio device into their 
usual care according to their preference (Nerivio only, medication only, both or 
none). Participants will be asked to report all their migraines or headaches at 
onset, regardless if they are using the device or not. For each migraine or 
headache, 
participants 
will 
be 
instructed 
to 
report 
headache 
level, 
presence/absence of associated symptoms, and use of medications at baseline, 2 
hours post report and 24 hours post report. 
Qualifying 
migraine 
headache 
A qualifying migraine headache is defined as a migraine headache that:  
1. Is of moderate or severe intensity and preceded by 24 hours of no pain or mild 
intensity pain; or is of mild intensity and preceded by 24 hours of no pain;  
2. Occurred in a setting in which the patient could properly administer the 
treatment (that is, it is possible to initiate a complete treatment within 60 
minutes of onset and the participant will be able to complete the migraine diary 
at 2 hours after treatment) 
Primary efficacy 
endpoint 
1. 
Pain relief at 2 hours post-treatment 
The proportion of subjects reporting, for the test treatment, pain relief at 2 
hours post-treatment without the use of rescue medication. Pain relief is 
defined as an improvement from severe or moderate pain to mild or no pain, 
or from mild pain to no pain. 

 
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Secondary 
efficacy 
endpoints 
 
1. Disappearance of associated symptoms at 2 hours post-treatment 
I. Disappearance of nausea in the test treatment at 2 hours post-treatment  
II. Disappearance of phonophobia in the test treatment at 2 hours post-
treatment 
III. Disappearance of photophobia in the test treatment at 2 hours post-
treatment  
 
2. Pain-free at 2 hours post-treatment 
The proportion of subjects reporting, for the test treatment, no pain at 2 hours 
post-treatment without the use of rescue medication. Pain-free is defined as 
improvement from mild, moderate, or severe pain to none 
 
Exploratory 
efficacy 
endpoints 
 
1. Within-subject consistency of the pain relief response 
Percentage of patients achieving pain relief at 2 hours in at least 50% of all 
their treatments (excluding the training treatment).  
2. Functional disability at 2 hours post-treatment 
The proportion of participants achieving improvement of at least one grade in 
functional disability in the test treatment at 2 hours post-treatment with no use 
of rescue medication 
3. Pain relief at 2 hours post-treatment as function of baseline pain level 
Percentage of patients achieving pain relief at 2 hours in the test treatment, 
for each level of pain at the beginning of the treatment. 
4. Sustained pain relief at 24 hours post-treatment 
The proportion of subjects achieving, for the test treatment, pain relief at 2 
hours post-treatment without the use of rescue medication and no relapse of 
headache pain within 24 hours 
5. Functional disability at 24 hours post-treatment 
The proportion of participants achieving improvement of at least one grade in 
functional disability  in the test treatment at 24 hours post-treatment with no 
use of rescue medication 
6. Within-subjects consistency of the pain-free response 
Percentage of patients achieving pain free at 2 hours in at least 50% of all 
their treatments (excluding the training treatment) 
 
Safety endpoints 
Rate of serious adverse events, adverse events and device-related adverse 
events 
Treatment tolerability  
Datasets 
1. Intent to treat analysis set (ITT) 
The ITT analysis set includes all patients who receive the device  
2. Modified intent to treat analysis set (mITT) 
The mITT analysis set includes all patients who treat a test treatment within 
60 minutes of the onset of migraine headache or aura.  
3. Per-protocol analysis set (PP) 
The PP analysis set includes all patients from the mITT analysis set without 
major protocol deviations. Main protocol instructions include: 
• The treatment has started within 60 minutes of the onset of migraine  
     headache or aura; 
• The treatment was administered to treat a qualifying migraine headache 

 
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• The treatment was administered for at least 30 minutes; 
• Pain level at 2 hours post-treatment was reported  
• The participant did not use rescue medication within 2 hours post- 
    treatment 
Data analysis 
The ITT analysis set will be used for the safety assessments and the mITT analysis 
set will be used for the efficacy assessments. The efficacy endpoints will be 
assessed on evaluable treatments of qualifying headaches. The within-subject 
consistency outcomes will be evaluated on up to 4 qualifying migraine headaches.  
 
 
 
 

 
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2. 
Background 
Migraine is one of the most prevalent and disabling neurologic disorders [1]. The 
International Headache Society defines chronic migraine as Headache occurring on 15 or 
more days/ month for more than three months, which, on at least eight days/month, has 
the features of migraine headache  [2].  
 
Chronic migraine affects approximately 1.4–2.2% of adults worldwide [3] and about 10% 
of the migraine population [4], however quality of life is more greatly affected in chronic 
migraine patients, than in episodic migraine populations [5].  
Treatment plan for chronic migraine consists of both prophylactic treatment and acute 
treatment. Although prophylactic medication have been shown to be efficacious for some 
patients [6], studies show very low adherence to preventive treatments [7] and high 
discontinuation rates mostly due to lack of efficacy and existence of side effects [8]. Yet, 
acute treatment, if used excessively, can often lead to medication overuse headache 
(MOH) [9]. Thus, there is a great unmet need for alternative non-pharmacological acute 
migraine treatments that are both effective and well tolerated. Such developments hold 
the potential to improve the health and quality of life of patients with chronic migraines. 
 
Non-invasive neuromodulation is safe, well-tolerated, and may have fewer adverse effects 
than drugs [10,11]. Remote electrical neuromodulation (REN) [12] is a novel acute 
migraine treatment which stimulates upper arm peripheral nerves to induce conditioned 
pain modulation (CPM) - an endogenous analgesia mechanism in which conditioning 
stimulation inhibits pain in remote body regions [13].  
 
The safety and efficacy of REN (Nerivio™, Theranica Bio-Electronics LTD., Israel) has 
been recently assessed for migraine in a randomized, double-blind, sham-controlled multi-
center study (NCT03361423). This study demonstrated that REN provides superior 
clinically meaningful relief of migraine pain and MBS compared to placebo, offering a safe 
and effective non-pharmacological alternative for acute migraine treatment. Specifically, 
the active stimulation was more effective than sham stimulation in achieving pain relief 
(66∙7% [66/99; CI95% 56∙48-75∙82] vs. 38∙8%, p<0∙001), pain-free (37∙4% vs. 18∙4%, 
p<0∙005) and MBS relief (46∙3% vs. 22∙2%, p<0∙001) at 2 hours post-treatment, and that 
the pain relief and pain-free superiority of the active treatment was sustained 48 hours 
post-treatment. In addition, the incidence of device-related adverse events was low and 
similar between treatment groups (4∙8% vs. 2∙4%, p=0∙49). All device-related adverse 
events were mild, did not required medical intervention and resolved within 24 hours. The 
device was granted a 510k De novo approval (DEN180059) for the acute treatment of 
migraine in people who do not have chronic migraine. 
The aim of the present study is to evaluate the safety and efficacy of REN for the treatment 
of chronic migraine.  
 

 
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3. 
Identification and description of the device information 
3.1. 
Intended use 
Current indication for use of the device: 
The Nerivio™ is indicated for acute treatment of migraine with or without aura in 
patients 18 years of age or older who do not have chronic migraine. It is a prescription 
use, self-administered device for use in the home environment at the onset of migraine 
headache or aura. 
 
This study aims to expand the current indication to include acute treatment of migraine 
in people with chronic migraine.  
 
3.2. 
Device description 
The device is a wireless wearable battery-operated stimulation unit controlled by a 
smartphone software application. Treatments with Nerivio™ are self-administered by 
the user at the onset of a migraine attack. 
 
The Nerivio™ is a fully integrated unit similar in appearance to an adhesive armband 
made of thermoplastic polyurethane (TPU). The device includes several main 
components:  
• 
A pair of electrodes covered with hydrogel and a removeable protective film 
• 
An electronic circuitry and a battery contained in a plastic case 
• 
A software that includes firmware and a software application for mobile platforms 
•  An armband to improve the adhesiveness and enable a discreet treatment 
 
The external side of the Nerivio™ (Figure 1) includes an "ON" switch and a LED 
indicator that signals various modes of operation, located on the enclosure. The internal 
side includes the electrodes and a biocompatible adhesive material that holds the 
device in its location. The armband is applied over the device to further secure its 
location on the arm and conceal the device to enable a discreet treatment. 
 
The device produces a proprietary electrical signal comprising a modulated 
symmetrical quad-phasic square pulse with a modulated frequency of 100-120-Hz, 
pulse width of 400 μs, and up to 40 mA output current (adjusted by the participant). 
 

 
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A 
B 
 
C 
 
Figure 1:  Nerivio™ device. (A) Internal side, (B) External side, and (C) The armband 
 
3.3. 
The application 
Activation, control over stimulation intensity and termination of stimulation are 
performed via a dedicated smartphone application and installed on the user’s 
smartphone (Figure 2). The application has a graphical user interface (GUI) which 
includes graphical controls that the user can select using a touch screen. The app 
enables the user to start treatments and control them as well as review the history of 
migraine headaches.  
 
 
 
 
Figure 2: The app screens 
 
The Nerivio application also includes a ‘migraine diary’ which collects information on 
the migraine episode and treatment (e.g. date & time, location, headache pain intensity, 

 
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etc.). The application also provides notifications and indications on connection state 
and remaining number of treatments.    
The device communicates with the mobile application software through a Bluetooth® 
radio protocol (BTLE) which uses 2.4GHz carrier.  
 
The application can be installed from Google Play or the App store and supports 
Hebrew and English menu displays. 
  
3.4. 
Operational context 
Nerivio™ is a wearable, battery-powered medical device for the acute treatment of 
migraines with or without aura. Nerivio™ delivers transcutaneous electrical nerve 
stimulation (TENS) through the control of the Nerivio™ iOS or Android app. Nerivio™ 
is a home-use device that requires prescription but does not require training. The device 
is provided with a printed QuickStart guide and a user manual in the app. The first use 
of the device requires the user to install the app and pair the smartphone to the device. 
In each treatment, the intensity level should be individually set so it feels strong yet 
comfortable and painless. The battery of the device is non-rechargeable, the electrodes 
should be covered with protective liners and the device should be stored in its original 
package.  
Nerivio™  should be placed on the user’s arm (Figure 3) at the onset of a migraine 
episode, the device should then be turned on and a treatment can be activated via the 
mobile application. The treatment includes a weak electrical current delivered to the 
skin via the electrodes. The arm was chosen for several reasons. First, it is distal from 
the head, enabling to produce CPM response. Second, it may be easily accessed 
independently by the user without the help of others. Finally, it provides a discreet 
location that maintains the privacy of the user and enables to continue with ongoing 
activities during treatment.   
 
Figure 3:  Nerivio™ location of treatment 
 

 
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3.5. 
Principle of operation 
Conditioned pain modulation (CPM) is a descending endogenous analgesic 
mechanism that originates in the brainstem (rostral ventromedial medulla), in which 
pain in one part of the body inhibits pain in multiple remote body regions [13]. According 
to this well-established mechanism, also known as “pain inhibits pain”, the intensity of 
a painful stimulus can be reduced by a second painful stimulus at a different location 
[14,15]. Notably, it has been shown that very strong but subjectively non‐painful 
stimulus is sufficient to trigger pain inhibitory effects [16].    
From a neuronal level, noxious sensory information is carried by two primary afferent 
fibers – the Aδ and C fibers (Table 1). Aδ fibers are small myelinated afferents that 
respond to mechanical and thermal stimuli, and carry rapid, sharp pain. These fibers 
are responsible for the initial withdrawal reflex responses. C fibers are unmyelinated 
and have a small diameter and low conduction velocity. These fibers respond to 
chemical, mechanical and thermal stimuli and produce slow, burning pain. The 
headache of migraine is believed to be mediated by activation of both types of fibers 
that innervate meningeal blood vessels [17]. CPM inhibits the responses of these fibers, 
with an inhibitory preference towards the C fiber mediated responses [18]. Another type 
of primary sensory afferent fibers is the Aβ fibers which are large and thickly myelinated, 
enabling rapid signal conduction (Table 1). These fibers have a low activation threshold 
and transmit tactile information. 
  
  Table 1:  Characteristics of nerve fibers 
Nerve fiber type 
A-delta 
C 
A-beta 
Diameter 
Medium (1-5 
microns) 
Small (< 2 
microns) 
Large (> 5 microns 
Myelination 
Thinly 
myelinated  
Unmyelinated 
thickly myelinated 
Signal 
propagation 
Medium (5-30 
mS-1) 
Slow (< 2mS-1) 
Fast (>35mS-1) 
Activation 
threshold 
High and Low 
High 
Low 
Sensation with 
stimulation 
Rapid, Sharp. 
Localized pain 
Slow, diffuse. 
Dull pain 
Tactile information 
 
In Nerivio™, the stimulation (secondary stimulus) is engineered to produce a strong but 
non-painful stimulus that invokes the CPM as a pain relief mechanism for the migraine 
headache (initial stimulus). The patient is instructed to adjust the intensity to the 
strongest stimulation which is still below the perceived pain level. The area of the 
electrodes of Nerivio™ is relatively large, enabling to recruit a large number of fibers 
during treatment. The pulse frequency and duration are designed so that C fibers and 

 
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Aδ fibers are stimulated below their thresholds, aiming to produce a local sensation 
below the pain threshold, as well as to avoid excitation of motor nerves. Furthermore, 
the local pain sensation in the arm may be inhibited by Aβ fibers through the “gate 
control” theory of pain [19], further preventing the perception of pain. In addition, the 
pulses frequency gradually changes during the stimulation to avoid pain habituation, 
and a low frequency modulating waveform is added to invoke the release of 
neurotransmitters to further enhance the analgesic impact. 
 
3.6. 
Output parameters 
Output parameters of the Nerivio™ are similar to those of other transcutaneous electrical 
nerve stimulation (TENS) devices previously approved by the FDA for adults and are 
currently marketed for different indications. 
The Nerivio™ output parameters and its comparison to other approved devices are 
described in Table 2.  
 
Table 2:  Key output parameters comparison 
Parameter 
Nerivio™  
Cefaly 
Sys*Stim TENS 
Mode or Program name 
TENS 
TENS 
TENS 
Waveform 
Biphasic, 
symmetrical 
Biphasic, 
symmetrical 
Asymmetrical 
biphasic with zero 
net DC 
Shape 
Rectangular 
Rectangular 
Rectangular 
Maximum output voltage 
(V)  
  
  
  
500Ω 
20 
8 
92 ±20% 
2KΩ 
60 
32 
144 ±20% 
10KΩ 
60 
60 
166 ±20% 
Maximum output current 
(mA)  
  
  
  
500Ω 
40 
16 
184 ±20% 
2KΩ 
30 
16 
72 ±20% 
10KΩ 
6 
6 
17 ±20% 
Duration 
of 
primary 
(depolarizing) 
phase 
(µsec) 
200 
250 
200µs ±10% 
Frequency (Hz) 
100-120 
60 
1-80Hz ±10% 
Maximum average power 
density (mW/cm²)500Ω 
1.14 
0.017 
12 
Maximum phase charge 
(µC) 
  
  
  
500Ω 
8 
4 
33.5u ±10% 

 
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Maximum current density 
(mA/cm², r.m.s) 
  
  
  
500Ω 
1.6 
2.37 
 
 
The user controls the stimulation intensity within the specified limits. A dedicated 
mechanism controls speed of intensity adjustment in order to protect the user from 
unexpected strong stimulation intensity variations.  
 
3.7. 
Instructions for use 
Device instructions for use will be available in a separate document which will be 
provided to the participants with the device and its package. 
 
3.8. 
Identification of the medical device 
The device label includes the address of the legal manufacturer and all other essential 
information, enabling complete traceability of the medical device, consistent with the 
regulatory labeling requirements. Investigational sites outside the USA, where the 
device is not yet approved, will receive a device with an additional label for clinical 
investigation use only. 
 
3.9. 
Training 
Participants will receive general instruction and will undergo training on using the device. 
The intended study population does not require special training but is expected to be 
familiar with smartphone use. The training will be administered by designated study 
personnel and will be recorded in a corresponding CRF. In addition, records of the 
training session will be documented in the study data base with a label “training”. The 
criteria for training effectiveness will be the ability of the participant to independently 
administer a training treatment session.  
 
The sponsor representative will be responsible to provide a formal training to the 
investigator and site personnel, which will include a demo and training activities. In order 
to provide additional support to the clinical personnel, a training video clip will be used 
at all training sessions for the study personnel and the participants.  
 
 
4. 
Preliminary investigations and justification for the study design 
4.1. 
Previous pre-clinical experience 
No animal studies were conducted with the Nerivio™ device. The necessity for an animal 
study has been deemed unnecessary since the device utilizes similar output parameters 
to those of FDA approved TENS devices, and in accordance with the application of risk 

 
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management according to EN ISO14791. Furthermore, there is no valid animal model 
to test the effectiveness of this device.  
 
4.2. 
Previous clinical experience 
The clinical data was obtained in one prospective, double-blind, randomized, crossover, 
sham-controlled pilot study and one prospective, randomized, double-blind, sham-
controlled pivotal studies (TCH-003). Both studies were conducted on adults (ages 18 
years or above). Each of these studies is briefly summarized below. 
   
4.2.1 Pilot study (NCT02453399) 
The pilot study was a single-center, prospective, double-blind, randomized, crossover, 
sham controlled pilot study to collect clinical data related to the safety and effectiveness 
of non-invasive remote electrical neuromodulation with Nerivio™ for the acute treatment 
of migraine. The results of this study have been published in Neurology [12]. Briefly, 86 
people with migraine with or without aura (in accordance with ICHD classification criteria) 
who had 2–8 attacks per month without preventive medications for at least 2 months 
were recruited. The participants were requested to treat migraine episodes at home 
using the device, which randomly provided five 20-minute-long stimuli programs 
differentiating in pulse width; 4 active programs at 80–120 Hz, with pulse widths of 200 
(P200), 150 (P150), 100 (P100), and 50 (P50) ms, and 1 placebo stimulation protocol 
(P0) at 0.1 Hz frequency with 45-ms-long pulses. 
 
Pain levels were self-reported using a 0-10 numeric rating scale (NRS) [20] via a 
smartphone application at onset and 10, 20, and 120 minutes after stimulation onset. 
The primary endpoint was the proportion of participants reporting pain decrease of at 
least 50% at 2 hours posttreatment in at least 50% of completed treatments.  
 
Participants 
A summary of the demographic characteristics of the participants is presented in Table 
3. The final analysis was performed on 71 participants who successfully treated at least 
one migraine attack and have not used rescue medications concurrently with the 
electrostimulation treatments.  
 
Table 3:  Demographic characteristics  
 
Female 
Male 
Sample size, n (%) 
69 (80) 
17 (20) 
Age, y, mean (min–max, SD) 
45.2 (22–72, 11.7) 
48.8 (26–67, 11.7) 
Migraine attacks per month, mean (SD) 
5.1 (2.7) 
5.34 (2.3) 
Migraine attacks per month, mean (SD) 
8.9 
8.6 
Occurrence of aura, n (%) 
40 (58) 
11 (65) 
 
 

 
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Efficacy 
The analysis of the primary endpoint revealed a 64% rate of at least 50% pain reduction 
(defined as a reduction from sever to moderate pain to mild or no pain) at 2 hours post-
treatment, in at least 50% of completed active treatments. This rate was significantly 
higher than the 26% rate found for the sham treatment (p=0.005). The data 
demonstrated that the P200 program was most effective for headache relief. Thus, the 
following pivotal study was conducted with the P200 program. 
 
Safety 
In this study no device-related adverse events and no side effects were reported. 
 
4.2.2 TCH-003 Pivotal study (NCT03361423) 
This was a randomized, double-blind, sham-controlled study conducted at 7 USA and 5 
Israeli sites from December 2017 to October 2018. This study aimed to assess the 
efficacy and safety of Nerivio™. 
 
Participants  
Eligible patients were 18–75 years old females and males who met the International 
Classification of Headache Disorders (ICHD) third edition criteria for migraine with or 
without aura, with at least two and no more than eight migraine headaches per month, 
with no more than 12 headache days per month, and with stable (or no) migraine 
preventive medications in the last two months prior to recruitment.  Exclusion criteria 
were: 1) pregnancy, nursing, trying to conceive; 2) pure menstrual migraine (excluded 
because these attacks are often longer); 3) implanted electrical device(s); 4) treatment 
with OnabotulinumtoxinA  in the prior month; 5) nerve blocks in the preceding two weeks; 
6) current use of cannabis; 7) uncontrolled epilepsy; 8) receiving parenteral infusions for 
migraine in the preceding two weeks; 9) other significant pain, medical or psychiatric 
illness that in the opinion of the investigator may confound the study assessments; 10) 
unable to use a smartphone; 11) previous experience with REN in clinical trials for 
migraine.  
 
Randomization and masking 
Before each site initiation, randomization schemes of blocks of eight participants per site 
(four active and four sham) were developed. Group allocation was concealed by 
randomization lists for each smartphone operating system (Android or iOS) prepared by 
the statistician of the data monitoring committee (DMC), which included the device media 
access control (MAC) address (the unique device identification number) and an assigned 
randomization number identifier. Participants were randomized based on the type of 
operating system of their phones (Android or iOS) and their order of arrival to the 
randomization visit.  To assess blinding, participants were asked at the end of study 
which group they thought they had been assigned to (active, sham, do not know). The 
participants, investigators and clinic personnel were unaware of group assignment until 

 
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the completion of the double-blind treatment phase. Each device was programmed with 
one of two versions of firmware that delivered either active or sham electrical stimulation 
(see above for detailed electrical properties). In all other aspects, the active and the sham 
conditions were kept similar.  
 
Procedures 
After enrollment, participants were trained to use the electronic diary application, 
installed on their own smartphones, and then completed a one-month migraine diary 
(“roll-in” phase). Eligible participants were then randomized in a 1:1 ratio to either active 
(active group) or sham stimulation (sham group), in a double-blind manner. During the 
randomization visit, participants were trained to use the device assigned to them, 
including finding the optimal individual stimulation intensity level (perceptible but not 
painful). Participants treated their migraine attacks for 4-6 weeks (“double-blind 
treatment” phase), starting at their optimal stimulation intensity, as soon as possible after 
migraine headache began and always within one hour of symptom onset. Participants 
were instructed to avoid taking rescue medications within two hours post-treatment, if 
possible. Pain scores (none, mild, moderate, or severe) were recorded at baseline, 2- 
and 48-hours post-treatment. Migraine associated symptoms including nausea, 
photophobia and phonophobia were recorded at the time of treatment. Participants 
declared their most bothersome migraine symptom (MBS) for each treated attack and 
reported absence and presence of all associated symptoms (including their MBS) at 
baseline and 2 hours post-treatment. At 2 hours, participants also subjectively reported 
whether they feel that a significant MBS relief was achieved.  
 
Outcomes 
The primary efficacy endpoint was the proportion of participants who achieved pain relief 
at 2 hours post-treatment in the "test treatment", defined as improvement from severe or 
moderate pain to mild or none, or, improvement from mild pain to none. The secondary 
efficacy endpoints pain-free (improvement from mild, moderate, or severe pain to none), 
MBS relief, pain relief & MBS relief, and MBS freedom at 2 hours post-treatment. 
Exploratory endpoints included 48-hour sustained pain-free and pain relief responses. 
An additional exploratory endpoint was within-subject consistency, defined as the 
proportion of participants achieving pain relief at 2 hours post-treatment in at least 50% 
of their treated attacks. Pain relief at 2 hours post-treatment as function of baseline pain 
level was also explored.       
 
Results 
296 participants were enrolled; 252 were randomized after the "run-in" phase, 126 were 
assigned to the active group and 126 to the sham group. Of the 44 who were not 
randomized, 33 failed to meet the “roll-in” criteria, 9 withdrew from the study and 2 were 
withdrawn by the investigator due to migraine misdiagnosis. Among the 252 randomized 
participants (intent-to-treat population), 7 withdrew from the study, 3 (1 sham, 2 active) 

 
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due to intolerance to the stimulation and 4 (2 sham, 2 active) were lost to follow up. 237 
participants completed at least one treatment (the "run-in" treatment) and 203 
participants completed the “test treatment”. 202 participants (99 in the active group and 
103 in the sham group) started the “test treatment” within one hour from symptom onset 
and reported pain level at 2 hours, forming the mITT population with evaluable data. 37 
participants who did not complete the “test treatment”, due to insufficient migraine 
attacks (n=18), participant’s decision not to use the device (n=4), other (n=6) or unknown 
(n=9), were excluded from the efficacy analyses. 
The demographic and clinical characteristics were similar between treatment groups 
(Table 4). The characteristics of treated migraine headaches were comparable to those 
reported in previous migraine studies [21–23].  
 
Table 4:  Demographic and clinical characteristics (intent-to-treat population) 
Characteristic 
Active group (n=126) 
Sham group (n=126) 
 
Age, y (SD) 
43.8 (12.25) 
41∙6 (11.81) 
 
Female, % (n/N) 
80.9% (102/126) 
80.9% (102/126) 
 
Caucasian, % (n/N) 
86.5% (109/126) 
88.9% (112/126) 
 
Triptan users, % (n/N) 
51.6% (65/126) 
44.4 (56/126) 
 
Migraine with aura, % (n/N) 
 
 
 
Often 
30.2% (38/126) 
26.2% (33/126) 
Rarely 
20.6% (26/126) 
23.8% (30/126) 
None 
49.2% (62/126) 
50.0% (63/126) 
MBS % (n/N)* 
 
 
 
None 
3.2% (4/126) 
0.8% (1/126) 
 
Nausea  
29.4% (37/126) 
24.6% (31/126) 
 
Photophobia 
43.7% (55/126) 
57.1% (72/126) 
 
Phonophobia 
20.6% (26/126) 
17.5% (22/126) 
 
Preventive medication use, % (n/N) 
28.6% (36/126) 
37.3% (47/126) 
 
Migraine attacks in the “roll-in” phase, n 
440 
437 
 
Treated migraine attacks in the “double-blind 
treatment” phase, n** 
 
385 
388 
 
Characteristics of the test treatment (mITT)  
P value 
Presence of aura in the “test treatment”, % 
(n/N)† 
19.2% (19/99) 
19.4% (20/103) 
0.96 
Baseline pain severity in the “test treatment”, % 
(n/N)† 
 
 
 
0.11 
    Mild 
35.4% (35/99) 
41.7% (43/103) 
 
    Moderate 
57.6% (57/99) 
44.7% (46/103) 
 
    Severe 
7.1% (7/99) 
13.6% (14/103) 
 
Presence of baseline associated symptoms in 
the “test treatment”, % (n/N)† 
 
 
 
    Nausea 
25.3% (25/99) 
24.3% (25/103) 
0.87 
    Photophobia 
63.6% (63/99) 
75.7% (78/103) 
0.06 
    Phonophobia 
55.6% (55/99) 
56.3% (58/103) 
0.91 
* Four participants in the active group reported allodynia as MBS (data not shown) **Participants were asked to 
treat up to four episodes †modifed intent-to-treat population 
 
In the active group, 66.7% participants (66/99; CI95% 56.48-75.82) achieved pain relief 
for the test treatment, compared to 38∙8% (40/103; CI95%, 29.39-48.94) in the sham 

 
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group, a therapeutic gain of 27.9% (p<0.001;Figure 4A).  Similar results were found when 
missing data was imputed using a worst-case scenario (66/103=64.1% for active versus 
41/104=39.4% for sham, p<0.001). Furthermore, more participants in the active group 
were pain-free at 2 hours post-treatment (37.4% [37/99; CI95% 27.85-47.67]) compared 
with the sham group (18.4% [19/103; CI95% 11.49-27.30]; a therapeutic gain of 19.0%; 
P=0.003, adjusted; Figure 4A). Rescue medication within 2 hours post-treatment was 
used by 1% of the participants in the active group and 3.8% in the sham group (p=0.19). 
The active treatment was also significantly more effective than sham for MBS relief 
(46.3% [44/95] vs. 22.2% [22/99]; CI95% 36.02-56.85 and 14.48-31.69 respectively; 
p<0.001, adjusted) and for combined pain relief & MBS relief (40.0% vs. 15.2%; CI95% 
30.08-50.56 active and 8.74-23.76 sham; p<0.001, adjusted) at 2 hours post-treatment 
(Figure 4B and Table 4). There was no statistically-significant difference between 
treatment groups in the 2 hours post-treatment MBS free response (40.7% [33/81] vs. 
36.4% [32/88]; CI 29.95-52.23 active and 26.37-47.31 sham; p=0.55, adjusted; Figure 
4B).  
The 2-hours pain relief and pain-free superiority of the active treatment were sustained 
48 hours post-treatment. Sustained pain relief at 48 hours post-treatment was achieved 
in 34 of 87 (39∙1%) participants in the active group, and in 15 of 89 (16.9%) participants 
in the sham group (P<0.005; Figure 4A). Sustained pain-free at 48 hours was achieved 
in the active group by 18 of 87 (20.7%) participants, and in the sham group by 7 of 89 
(7.9%) participants (P<0.05; Figure 4A). 
During the 4-6 weeks period of the double-blind treatment phase, participants in the 
active group treated an average of 3.5 attacks per participant versus an average of 3.6 
attacks per participant in the sham group. Pain relief at 2 hours post-treatment for at 
least 50% of treated attacks was higher in the active group compared to the sham group 
(62.6% [62/99] vs. 45.6% [47/103], p=0.015). 

 
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Figure 4:  Efficacy endpoints. (A) Pain response at 2- and 48-hours post-treatment. (B) 
MBS response at 2 hours post-treatment. The error bars represent 95% confidence 
intervals.         ***p<0.001, **p<0.005, *p<0.05. MBS=most bothersome symptom.   
 
 
The primary endpoint was also evaluated as a function of baseline pain intensity. The 
interaction between baseline pain intensity and response rate was not found significant 
(p=0.84), indicating that the treatment effect was similar across baseline pain intensity 
levels.  
 
Safety analyses were performed on all 252 participants (ITT population). The percentage 
of participants experiencing at least one adverse event was 13.5% (34/252) and was 
comparable across treatment groups (15.1% [19/126] active and 11.9% [15/126] sham, 
p=0.58). 23 device-related adverse events were reported during 773 treatments (2.7%), 
14 in the active group and 9 in the sham group. The incidence of device-related adverse 
events was low (3.6%), and similar between treatment groups (6/126 [4.8%] vs. 3/126 
[2.4%]; p=0.49). Device-related adverse events included warmth sensation, temporary 
arm/hand numbness, redness, itching, tingling, muscle spasm and pain in the arm, 
shoulders or neck (Table 5). All device-related adverse events were mild, resolved within 
24 hours and did not require medical treatment. There were no device-related serious 

 
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adverse events, no unanticipated adverse device effects and none of the participants 
withdrew from the study due to adverse events.  
 
 
Table 5:  Incidence of adverse events and device-related adverse events in the ITT population 
 
The findings of this study suggest that remote electrical neuromodulation with Nerivio™ 
is an effective acute migraine treatment with a favorable safety and tolerability profiles. 
REN may be an alternative acute migraine treatment with comparable or superior 
efficacy to commercially available neuromodulation devices [21,24]. REN has the 
potential to increase patient adherence, improve migraine management and improve the 
health and quality of life of people with migraines.   
 
4.3. 
Clinical investigation risks and benefits  
4.3.1. 
Anticipated benefits to participants  
The clinical studies conducted in adults demonstrated that REN provides superior 
clinically meaningful relief of migraine pain and MBS compared to sham-device with a 
favorable safety profile, offering a safe and effective non-pharmacological alternative for 
acute migraine treatment. It is anticipated that the use for chronic migraines will be 
experienced with a similar clinically beneficial effect.  
 
4.3.2. 
Risks and adverse effects 
The results of the pivotal study demonstrate a favorable safety profile of the device.  In 
this study, adverse event incidence was low; mainly reports of sensation of warmth, 
redness and numbness of the arm/hand. All device-related adverse events were mild, 
resolved within 24 hours and did not require medical treatment (Table 5). There were 
no device-related serious adverse events, no unanticipated adverse device effects and 
 
Active (n=126) 
Sham (n=126) 
P value 
Patients reporting at least one adverse event, % (n/N) 
15.1% (19/126) 
11.9% (15/126) 
0.58 
Device-related adverse events, % (n/N) 
4.8% (6/126) 
2.4% (3/126) 
0.49 
Device-related adverse events incidence 
 
Warmth sensation, % (n/N) 
2.4% (3/126) 
0.8% (1/126) 
0.62 
Numbness in the arm/hand, % (n/N) 
0.8% (1/126) 
0% (0/126) 
1.00 
Redness, % (n/N) 
1.6% (2/126) 
0.8% (1/126) 
1.00 
Itching, % (n/N) 
0.8% (1/126) 
0% (0/126) 
1.00 
Neck and shoulder pain, % (n/N) 
0% (0/126) 
0.8% (1/126) 
1.00 
Pain in the arm, % (n/N) 
1.6% (2/126) 
0% (0/126) 
0.49 
Tingling, % (n/N) 
0% (0/126) 
0.8% (1/126) 
1.00 
Muscle spasms, % (n/N) 
0.8% (1/126) 
0% (0/126) 
1.00 

 
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none of the participants withdrew from the study due to adverse events. The safety 
profile of the device is favorable compared to triptans [25] and to new pharmacological 
agents, such as centrally acting serotonin (5-HT1F) agonists that lack cardiac 
vasoconstrictive activity [26]. Furthermore, the device has comparable or superior 
efficacy to commercially available neuromodulation devices [21,24]. 
   
4.3.3. 
 Risk-benefit balance 
The data collected in the randomized controlled clinical study in adults demonstrated 
that acute treatment of migraine with Nerivio™ results in most important clinical benefits 
with a very low risk to the patient. Invoking conditioned pain modulation using peripheral 
neurostimulation that induces a general analgesic effect resulted in favorable 2-hour 
pain relief and pain-free responses which are comparable with pharmacological acute 
migraine treatments such as triptans with a more favorable safety profile. Overall, the 
benefit-risk balance of Nerivio™ is favorable. The overall risk posed by the device is 
minimal. The device offers a major benefit by providing a novel acute treatment of 
migraines which is highly effective and reduces the side effects of current 
pharmacological treatments. Therefore, the device may offer an alternative non-
pharmacological treatment approach to the limited effective treatment options for 
chronic migraines and has the potential to decrease the reliance of patients on 
pharmacological treatments, improve treatment adherence, reduce the risk of 
medication overuse and considerably improve the health and quality of life of patients 
suffering from chronic migraines. 
 
5. 
Objectives & hypotheses  
5.1. 
Study objectives 
The objective of this study is to evaluate the safety and efficacy of Nerivio™ for the acute 
treatment of migraine in people with chronic migraine. The goal of this study is to 
demonstrate migraine headache relief without unexpected device-related adverse 
effects. 
 
5.2. 
Study hypothesis 
The hypothesis of this study is that in people with chronic migraine, REN with Nerivio™ 
will provide clinically meaningful relief of migraine pain with a favorable safety profile.  
 
6. 
Study design  
6.1. 
Participants 
This study will be conducted on up to 150 eligible participants.  
 

 
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6.1.1. 
Inclusion criteria 
• Participants aged 18-75 years old 
• Participants meeting the ICHD-3 diagnostic criteria for chronic migraine  
• Participants experiencing between 15 to 23 headache days per month, with at least 
8 headache days (per month) with migraine phenotype presentation 
• Participants have personal access to a smartphone 
• Participants must be able and willing to comply with the protocol 
• Participants must be able and willing to provide written informed consent 
 
6.1.2. 
Exclusion criteria 
• Participants with an active implanted electrical and/or neurostimulator device (e.g. 
cardiac pacemaker, cochlear implant). 
• Participants with congestive heart failure (CHF), severe cardiac or cerebrovascular 
disease. 
• Participants with uncontrolled epilepsy. 
• Lack of efficacy, after an adequate therapeutic trial, of at least two migraine specific 
acute medications.  
• Change in migraine preventive medications (type or dose) in the last two months prior 
to recruitment and/or during the study  
• Pregnant, trying to get pregnant or breastfeeding female participants 
• Subjects participating in any other interventional clinical study. 
• Participants without basic cognitive and motor skills needed to operate a smartphone 
• Participants with other significant pain, medical or psychological problems that in the 
opinion of the investigator may confound the study assessments  
• Participants who have previous experience with the device 
 
6.1.3. 
Contraindications 
• The device should not be used by people with congestive heart failure (CHF), severe 
cardiac or cerebrovascular disease. 
• The device should not be used by people with uncontrolled epilepsy. 
• The device should not be used by people with active implantable medical device, such 
as a pacemaker, hearing aid implant, or any implanted electronic device. Such use 
could cause electric shock, electrical interference or serious injuries or medical 
conditions. 
 
Main warnings and precautions: 
• The device should not be used over skin conditions, such as open wounds or rashes, 
or over swollen, red, infected or inflamed areas or skin eruptions or fragile skin on the 
upper arm at the treatment location.  

 
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• The device should not be shared with other people. The device is intended to be used 
by a single person to avoid skin disease or any transmissible disease. 
• The device should not be used on the heart, chest, neck, head or any other body 
location other than the upper arm, because this could cause severe muscle spasms 
resulting in closure of your airway, difficulty in breathing, or adverse effects on heart 
rhythm or blood pressure.  
• The device has not been evaluated for use in pregnant women and people less than 
18 years of age    
 
6.1.4. 
Withdrawal/discontinuation 
Participants may withdraw consent at any time and do not have to provide an 
explanation.  
 
Participant may be withdrawn from the study by the PI or sponsor due to one or more 
of the following reasons: 
• Participant is lost to follow-up 
• Refusal of the participant to continue treatment and/or follow-up observations 
• Serious adverse event 
• Participants encountering difficulties with the investigational product (IP) (e.g. 
cannot tolerate the treatment, unable to operate the application) 
• Significant protocol deviation/violation or noncompliance, either by the patient or 
the investigator 
• Decision made by the investigator that termination is in the patient’s best medical 
interest 
• Device malfunction 
• Other ethical or clinical considerations upon investigator discretion 
 
6.2. 
Stimulation program  
The device produces a proprietary electrical signal comprising a modulated symmetrical 
biphasic square pulse with a modulated frequency of 100-120-Hz, pulse width of 400 μs, 
and up to 40 mA output current (adjusted by the participant). The duration of the 
treatment is 45 minutes.  
 
6.3. 
Procedures 
This open label study includes up to four visits. The enrollment and application training 
may occur in two separate visits instead of one.    
 
First visit –  
The first visit will include screening, enrollment and training on the application. 
 

 
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Enrollment: The screening process will include an eligibility assessment and a urine 
pregnancy test. Following successful screening, the site staff will provide the participants 
with study related information, perform an enrollment interview and receive an informed 
consent from the participants. During this visit, participants will complete baseline 
questionnaires that included information on the frequency and severity of their migraine 
attacks, typical associated symptoms, use of preventive and acute treatments, and the 
effect that their migraine attacks have on their daily routine and quality of life. 
 
Application training: Eligible participants who enroll to the study will be trained to use 
the diary mode of the application that is installed on their own smartphones. The 
participants will be instructed to report the onset of all their migraines and headaches 
and  complete a migraine diary questions regarding their pain intensity levels, the 
presence/absence of aura and associated migraine symptoms (nausea, photophobia, 
phonophobia, and allodynia) as well as rate their stress level and functional disability at 
baseline, 2- and 24-hours post-treatment. At the beginning of each treatment, 
participants will also be asked to report the time elapsed from attack onset. The site 
personnel will be required to document the training session in the CRF.  
 
Run-in phase: After the enrollment visit, participants will undergo a 4-week migraine 
diary phase aimed to collect baseline migraine characteristics and further assess 
eligibility. The participants will use the app to record pain intensity levels, the 
presence/absence of aura and associated migraine symptoms (nausea, photophobia, 
phonophobia, and allodynia) as well as the effect that their migraine attacks have on 
their daily routine and quality of life, at baseline, 2- and 24-hours post-treatment. These 
reports will be transferred by the application to the electronic data capture (EDC) system, 
where they will be collected and registered.  
Participants who report at least 6 qualifying migraine headaches with pain data at 
baseline and 2 hours post-treatment will continue to the treatment phase.  
 
Second visit- 
Device training: Eligible participants who successfully complete the run-in phase will 
receive the Nerivio™ device. The device will be registered and connected by Bluetooth 
to their smartphone. During this visit, participants will be trained to use the device. Device 
training will include finding the optimal individual stimulation intensity level (perceptible 
but not painful), that will be subject to change during the treatment phase. The site staff 
will also carefully review with the patient how to identify a qualifying migraine headache 
(see below) and provide detailed instructions on study procedures.  
 
If the research staff recognizes that the participant cannot tolerate the feeling of the 
electrical stimulation, the participant may be withdrawn from the study.  
 

 
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During the training, participants will also be informed on the key elements which are 
critical for the successful conduct of the study: 
• 
Treatments of migraine and headaches with Nerivio™ should be performed as 
soon as possible after migraine headache or aura began and always within one 
hour of symptoms onset. Treatments of mild headaches are accepted.  
• 
 Avoid taking rescue medications within two hours post-treatment (2 hours from 
start of treatment), if possible. 
• 
The treatment should be performed for at least 30 minutes (the recommended 
treatment duration is 45 minutes).  
 
The site personnel will be required to document the training session in the CRF. 
 
Treatment phase: Participants will be instructed to use the device for the treatment of 
migraine and/or headaches (see below) as soon as possible and always within 60 
minutes of onset during a period of up to 4 weeks. Participants will be instructed to use 
the device with the intensity level identified during the device training visit (and adjust as 
necessary) and make sure the stimulation is perceptible but not painful. Participants will 
be instructed to avoid taking rescue medications within 2 hours post-treatment. If 
medications are used, participants will be instructed to record in the app when and which 
medication was taken at 2- and 24-hours post treatment. The participants will use the 
app to record pain intensity levels, the presence/absence of aura and associated 
migraine symptoms (nausea, photophobia, phonophobia, and allodynia) as well as the 
effect that their migraine attacks have on their daily routine and quality of life, at 
baseline, 2- and 24-hours post-treatment. At the beginning of each treatment, 
participants will also be asked to report the time elapsed from attack onset. Adverse 
events will be reported throughout this phase of the study directly to the site staff. 
 
Participants who do not achieve satisfactory relief at 2 hours post-treatment may treat 
again with the Nerivio™ device or may treat with usual care at that time or any time 
thereafter if the headache does not resolve. Participants will also be able to treat 
headache recurrence with the device. Migraine headaches that are not treated with the 
device may be treated with usual care.  
 
The first reported treatment will be considered a "training" treatment, aimed to verify that 
the participants use the device properly, and will only be included in the safety analysis. 
The efficacy evaluation will be performed on the first treatment of a qualifying attack (see 
below) following the training treatment (hereby termed “test treatment”). 
 
Qualifying migraine headache 
A qualifying migraine headache is defined as a migraine headache that:  

 
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1. Is of moderate or severe intensity and preceded by 24 hours of no pain or mild 
intensity pain; or is of mild intensity and preceded by 24 hours of no pain  
AND 
2. Occurred in a setting in which the patient could properly administer the treatment 
(that is, it is possible to initiate a complete treatment within 60 minutes of onset 
and the participant will be able to complete the migraine diary at 2 hours after 
treatment) 
 
Third visit- Follow-up phase: 
Following the 4-week period of the treatment phase, participants will return to the clinic 
to fill questionnaires assessing satisfaction and user experience. All participants who 
complete the treatment phase will enter an additional 8-week phase in which the device 
can be incorporate into their usual care. Participants will treat their migraines and 
headaches according to their preference- treatment with Nerivio only, treatment with 
medication only, both treatment options, or none. Participants will be asked to report all 
their migraine headaches at onset (migraines or headache), regardless if they are using 
the device or not. The participants will use the app to record pain intensity levels, the 
presence/absence of aura and associated migraine symptoms (nausea, photophobia, 
phonophobia, and allodynia) as well as the effect that their migraine attacks have on 
their daily routine and quality of life, at baseline, 2- and 24-hours post-treatment. 
Fourth (final) visit – End of study:  
Participants will return to the clinic following the end of the follow-up phase, at which time 
they will return the device. The participants will have the option of returning the device 
by mail instead of an on-site visit. Participants may be asked to fill additional 
questionnaires on their migraine and their experience with the device.  
 
6.3.1. 
Study duration 
The duration of the study for each participant is expected to be 16 weeks.  
 
6.4. Study endpoints 
6.4.1. Primary efficacy endpoint 
Pain relief at 2 hours post treatment 
The proportion of subjects reporting, for the test treatment, pain relief at 2 hours 
post-treatment without the use of rescue medication. Pain relief is defined as an 
improvement from severe or moderate pain to mild or no pain, or from mild pain 
to no pain. 
 

 
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6.4.2. Secondary efficacy endpoints 
1. Disappearance of associated symptoms at 2 hours post-treatment 
I. Disappearance of nausea in the test treatment at 2 hours post-treatment  
II. Disappearance of phonophobia in the test treatment at 2 hours post-treatment 
III. Disappearance of photophobia in the test treatment at 2 hours post-treatment 
 
2. Pain-free at 2 hours post-treatment: 
The proportion of subjects reporting, for the test treatment, no pain at 2 hours post-
treatment without the use of rescue medication. Pain-free is defined as 
improvement from mild, moderate, or severe pain to none 
 
6.4.3. Exploratory efficacy endpoints 
1. Within-subject consistency of the pain relief response 
 Percentage of patients achieving pain relief at 2 hours in at least 50% of all their 
treatments (excluding the training treatment)  
 
2. Functional disability at 2 hours post-treatment 
The proportion of participants achieving improvement of at least one grade in 
functional disability in the test treatment at 2 hours post-treatment with no use of 
rescue medication 
 
3. Pain relief at 2 hours post-treatment as function of baseline pain level 
 
4. Sustained pain relief at 24 hours post-treatment 
The proportion of subjects achieving, for the test treatment, pain relief at 2 hours post-
treatment without the use of rescue medication and no relapse of headache pain 
within 24 hours 
 
5. Functional disability at 24 hours post-treatment 
 
The proportion of participants achieving improvement of at least one grade in 
functional disability in the test treatment at 24 hours post-treatment with no use of 
rescue medication 
 
6. Within-subjects consistency of the pain-free response 
Percentage of patients achieving pain free at 2 hours in at least 50% of all their 
treatments (excluding the training treatment) 
 
6.4.4. Safety endpoints 
1. Device safety   
 The incidence of adverse events in general and by seriousness, severity and 
association to the device.  

 
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2. Treatment tolerability  
The percent of subjects who fail to complete the study because of adverse events 
 
6.5. 
Methods and timing of assessing and analysing variables 
Once the last patient completes the treatment phase of the study and all the queries will 
be resolved, the database will be locked, cleaned and exported for final statistical 
analysis. A study report will be issued following the final database lock.  
 
6.6. 
Data management 
The data management function will be supported by a cloud-based electronic data 
capture (EDC) system developed by FlaskData.IO (Modi’in, Israel). FlaskData.IO 
provides services for collection and remote monitoring of clinical trials data, compliant 
with HIPAA and 21 CFR Part 11. EDC portals with secure authorized access will be 
made available to every participating site, as well as to the study monitor.  
 
Data captured by the clinical personnel will be entered directly into pre-specified eCRF 
screens by the site personnel. Data from paper sources will be entered into the study 
database. Automatic data checks will be implemented for majority of entry fields to 
provide opportunity for resolving data inconsistencies as soon as possible to its 
occurrence. Efforts will be made to identify missing or incorrect data and promptly resolve 
these issues.  
 
Data collected by the smartphone application will be directed to a secured cloud-based 
database where it will undergo analysis aimed at detecting of missing data and other 
inconsistencies. The smartphone will transmit PRO and technical data containing 
activation times, stimulation intensity and ePRO via the smartphone to a central 
electronic database for analysis. Activities such as repeatedly aborted programs, missing 
feedbacks, inconsistent stimulation intensity adjustments, will be communicated to the 
research coordinator of the corresponding site, using the participants’ ID codes. 
Automated means were developed to identify and provide corresponding notifications 
regarding events that may lead to protocol deviations and/or missing data, and which 
resolution may require involvement of study personnel. Examples of such events include 
missing PRO data or low device battery level. An automated system was implemented 
to notify the participant, site study coordinator and the sponsor’s study monitor of such 
issues. Missing data will be automatically identified by a script running on the cloud of 
FlaskData.IO, and queries will be generated to the participants and the corresponding 
site study coordinator. Near real time detection of problems in accumulating data will 
allow timely generation and resolution of queries. Intermediate data processing and 
translation into eCRF format will be performed. Processed data are further pushed into 
the EDC system. 

 
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A daily back-up of the database will be performed.  In addition, a copy of each 
participant’s ePROs and other activities will be stored in his/her smartphone memory and 
can be retrieved if needed.   
EDC tools will be used for locking the database and exporting to SAS compatible format 
for interim and final statistical analyses. Query resolution will also be performed using 
EDC tools. 
All paper-based source data and relevant medical documents that also serve as source 
documents will be maintained by the sites and will be available as eCRF attachments. 
participant identification will be removed from all data and the participants will be 
identified by their codes. The site investigator is responsible for ensuring that eCRFs are 
filled in a timely manner and that relevant paper documents are properly stored. The 
investigators will provide the documents to the sponsor either through the sponsor 
representative or by mail per the sponsor’s request. 
Access to data will be authorized and controlled, in accordance with relevant regulations 
and guidelines. 
 
The study will be performed according to the protocol. At each site, the PI will appoint 
staff member(s) that will be responsible for completing the CRFs supplied by the 
sponsor. 
Specifics of data query handling are given in data management and monitoring plans.  
Audit trail for data entry and corrections will be maintained. 
 
 
7. 
Statistical Considerations 
7.1. 
Study design and aim 
The study is designed as a prospective, open label, single arm, multicenter study. This 
study aim is to evaluate the efficacy and safety of NerivioTM for the acute treatment of 
migraine in people with chronic migraine. 
  
7.2. 
Endpoints 
7.2.1. Primary efficacy endpoint 
The primary efficacy endpoint of the study is pain relief at 2 hours post treatment without 
use of rescue medication. Pain relief is defined as an improvement from severe or 
moderate pain to mild or no pain, or from mild pain to no pain. 
 
7.2.2. Secondary efficacy endpoints 
Secondary efficacy endpoints include: 

 
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• Proportion of subjects reporting, for the test treatment, nausea at baseline and 
achieving absence of nausea at 2 hours post treatment without use of rescue 
medication. 
• Proportion of subjects reporting, for the test treatment, phonophobia at baseline 
and achieving absence of phonophobia at 2 hours post treatment without use of 
rescue medication. 
• Proportion of subjects reporting, for the test treatment, photophobia at baseline 
and achieving absence of photophobia at 2 hours post treatment without use of 
rescue medication. 
• 
Proportion of subjects reporting, for the test treatment, pain-free at 2 hours post 
treatment without use of rescue medication. Pain free is defined as an 
improvement from mild, moderate or severe pain to no pain. 
 
7.2.3. Exploratory efficacy endpoints 
Exploratory efficacy endpoints include: 
• Percentage of patients achieving pain relief at 2 hours in at least 50% of all their 
treatments (excluding the training treatment). The within-subject consistency 
outcomes will be evaluated on up to 4 qualifying migraine headaches. 
• Proportion of subjects achieving, for the test treatment, improvement of at least 
one grade in functional disability at 2 hours post treatment without use of rescue 
medication. 
• Percentage of patients achieving pain relief at 2 hours in the test treatment, for 
each level of pain at the beginning of the treatment. 
• Proportion of subjects achieving, for the test treatment, pain relief at 2 hours post 
treatment without use of rescue medication and no relapse of headache pain 
within 24 hours. 
• Proportion of subjects achieving, for the test treatment, improvement of at least 
one grade in functional disability at 24 hours post treatment without use of rescue 
medication. 
• Percentage of patients achieving pain free at 2 hours in at least 50% of all their 
treatments (excluding the training treatment). The within-subject consistency 
outcomes will be evaluated on up to 4 qualifying migraine headaches. 
 
7.2.4. Safety endpoints 
The safety endpoints of adverse events and tolerability will be assessed by 
review of all safety parameters, including adverse events. 
The incidence of adverse events will be assessed as a function of severity and 
association to the device. The time of resolution of the adverse events and 
need for treatment will also be analysed.   
 

 
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7.3. 
Sample size 
A sample size was calculated on the efficacy endpoint of pain relief at 2 hours post-
treatment. Calculations show that a sample size of 110 participants would provide 80% 
power to determine that 60% (±6%) of the participants will achieve pain relief at 2 hours 
post-treatment. The sample size may be increased to up to 120 participants to account 
for a potential ~10% drop-out rate and/or missing data.  
 
7.4. 
Analysis sets 
Intent to treat analysis set (ITT) 
The ITT analysis set includes all patients undergoing the treatment phase.  
  
Modified intend to treat analysis set (mITT) 
The mITT analysis set includes all patients undergoing the treatment phase and treat a 
test treatment within 60 minutes of migraine symptoms onset. Subjects with no valid post 
baseline assessment will not be included in the relevant analysis.   
 
Per-protocol analysis set (PP) 
The PP analysis set includes all patients from the mITT analysis set without major 
protocol deviations. Main protocol instructions include: 
• 
has started within 60 minutes of migraine symptoms onset 
• 
was administered to treat a qualifying migraine headache 
• 
was administered for at least 30 minutes 
• 
includes data on pain intensity at 2 hours post-treatment 
• 
rescue medication was not used before or within 2 hours post-treatment 
 
Statistical analysis of the analysis sets 
 
The ITT analysis set will serve as the main set for safety assessments. 
The mITT analysis set will serve as the primary set for the efficacy assessment.  
 
7.5. 
Statistical analysis  
7.5.1. General considerations 
Statistical analyses will be performed using SAS® v9.4 or higher (SAS Institute, Cary 
NC, USA). 
Baseline demographic and other baseline characteristics, together with safety analyses 
will be performed on all participants who underwent the treatment phase. Baseline 
values are defined as the last valid value prior to treatment. 
Where confidence limits are appropriate, a two-sided 95% confidence interval will be 
constructed.  

 
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7.5.2. Demographic and other baseline variables 
Demographic and baseline condition related characteristics will be tabulated. 
Continuous variables will be summarized by a mean, standard deviation, minimum, 
median and maximum, and categorical variables by a count and percentage. 
 
7.5.3. Efficacy analysis 
The efficacy endpoints will be assessed on evaluable treatments of qualifying migraine 
headaches. The first use of the device is considered a training treatment and will not 
be included in the efficacy analyses. The first treatment of a qualifying migraine 
headache after the training treatment is considered a test treatment and will be used 
for all efficacy assessments. If this treatment is not evaluable (i.e., no pain data at 2 
hours post-treatment), a subsequent treatment of a qualifying migraine headache with 
evaluable data will be considered the test treatment.   
Use of rescue medication before the 2-hours assessment will be considered a 
treatment failure for the 2-hours endpoints, and before the 24 hours assessment for the 
sustained 24-hours endpoints. The percentage of participants achieving each of the 
efficacy outcomes will be presented in a tabular form along with two-sided 95% exact 
confidence intervals.  
For the associated symptoms outcomes, the observed response proportions and 
corresponding 95% exact confidence intervals for each associated symptom will be 
provided. All patients with baseline and 2 hours values will be included in the analyses. 
A response in each associated symptom (nausea, vomiting, photophobia, 
phonophobia) is defined as change from presence of a specific associated symptom at 
baseline to absence of the same associated symptom at 2 hours post-treatment.  
 
In addition, logistic regression models will be used to assess the efficacy. Baseline 
value and site will serve as covariates. 
The efficacy endpoint (pain relief at 2 hours) may also be evaluated in attacks with aura 
and attacks without aura separately. 
 
7.5.4. Safety analysis 
Safety and tolerability will be assessed by review of all safety parameters, including 
adverse events. Serious adverse events, device-related SAEs, adverse events (by type 
and overall), device-related AE, adverse device reactions and device malfunction rates 
will be documented. Treatment tolerability, the number and percent of subjects who fail 
to complete the study and the number and percent of subjects who fail to complete the 
study because of adverse events will be presented. Time to withdrawal will also be 
assessed and presented by Kaplan-Meier curves. 
 

 
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7.5.5. Treatment by sites interaction 
Poolability across centers may be assessed using logistic regression. Centers with less 
than 10 subjects will be grouped together by geographical area. If the center term is 
found significant (p<0.1), the reason for this interaction will be further explored. This 
evaluation may include demographic features, symptoms at presentation, clinical and 
treatment history, and site comparability in the features found to be associated with the 
primary endpoint variables. Adjustment for other covariates such as demographics or 
other baseline subject characteristics may be performed by adding these variables into 
a logistic regression model. 
The analysis may be repeated for US sites vs. out of US (OUS) sites. 
 
7.5.6. Handling of missing data 
Sensitivity analyses of the efficacy endpoints may be performed to assess the impact 
of missing data of pain severity at 2 hours post-treatment on the efficacy outcomes. 
This will be performed using several possible imputation methods including, but not 
limited to: 
• Observed data: use only treatments with non-missing pain data who did not 
withdraw early from study. 
• Dropout/AE Imputation: a subject with no post baseline measurement of pain or 
a subject withdrawn due to an adverse event or treatment intolerability should be 
considered as a non-responder for this analysis. 
• Worst Case Scenario: assumes that all subjects with missing pain data are 
failures. 
• Best Case Scenario: assumes that all subjects with missing pain data are 
successes. 
 
8. 
Data management 
8.1 
Data capture 
Data capture will be performed using an electronic data collection (EDC) system in 
conjunction with electronic patient reported outcome (PRO) collection tools implemented 
in the smartphone application. The clinical sites will use electronic case report forms 
(eCRFs) to document the information required by the study CIP. 
The EDC provider is FlaskData.IO. The EDC enables secure collection, transmission, 
validation, monitoring and real-time administration of the data collected at the sites and 
by the smartphone application. The system offers a password-restricted access to 
clinical trial information based on individuals' roles and responsibilities. The EDC is 
compliant with 21 CFR Part 11 and FDA’s “Guidance: Computerized Systems Used in 
Clinical Investigations.” 
Except for patient reported outcomes which are directly reported by the participants in 
the smartphone application, data reported on the eCRF should be driven from source 

 
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documents and should be consistent with these source documents. Editing of data will 
be done with a full audit trail. 
PRO data collected from the smartphone application will be saved in dedicated log files 
on the smartphones for backup purposes and transferred to the EDC system. 
  
8.1.1. Direct data entry 
For several CRF fields, source data verification (SDV) may not be possible as entries 
may not be found in source documents (i.e. patient reported outcome completed 
directly into the smartphone app). Therefore, the CRF may be used for direct data entry, 
but only in pre-defined fields. 
  
8.2 
Data quality assurance 
To ensure the quality of clinical data across all subjects, a clinical data management 
review of the patient data in the CRF will be performed by the sponsor. During this 
review, patient data will be assessed for consistency, omissions, and any apparent 
discrepancies. In addition, the data will be reviewed for adherence to the CIP and 
relevant regulations. To resolve any questions arising from the clinical data management 
review process, data queries and/or site notifications will be issued by the sponsor. 
Discrepancy resolution will be documented within the database audit trail. 
 
8.3 
Electronic signatures 
The PI will electronically sign each individual eCRF after the data has been cleaned, 
monitored and reviewed. The electronic signature asserts that the investigator reviewed 
the eCRFs, the data queries, and the site notifications, and agrees with the content. Any 
changes made to the data after an electronic signature has been applied will result in 
invalidation of the original signature, and the PI will be required to re-sign the data after 
reviewing the change(s). 
 
8.4 
Verification, validation and securing of electronic data capture 
system 
Verification and validation of the EDC and eCRFs will be performed by a team comprising 
representatives of the developer, the sponsor and at least one of the participating sites. 
A verification and validation report will be detained by the sponsor.  
 
8.5 
Records and data retention 
A copy of all records (e.g., informed consent documents, source data, safety reports, 
study device dispensing records, etc.) which support case report forms for this study, will 
be retained in the files of the responsible investigator for a minimum of five (5) years 
following notification by the sponsor that all investigations (not merely the investigator's 
portion) are completed, terminated and/or discontinued.  If the principal investigator 

 
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retires, relocates, or for other reasons withdraws from the responsibility of keeping the 
study records, custody must be transferred to a person who will accept the responsibility.  
The sponsor must be notified in writing of the name and address of the new custodian 
within 5 days after such transfer occurs. 
 
The database will be retained by the EDC system provider for a minimum of 5 years. 
 
8.6 
Other aspects of clinical quality assurance  
The site PI or a person designated by the site PI is responsible for establishing and 
maintaining compliance with the study protocol. The study PI is responsible for 
addressing quality assurance issues (e.g. correcting procedures that are not in 
compliance with the protocol). The study coordinator is responsible for quality control 
issues (e.g. correcting errors in data entry). The sponsor will monitor the investigational 
sites throughout the study. All outstanding issues and findings that site personnel 
become aware of will be communicated and handled in agreement with a monitoring 
plan. An independent DMC will be responsible for providing oversight of the data 
monitoring issues and conducting periodical reviews that may include recommendations 
regarding enrollment, continuation, modification, or termination of the study.   
Site audits by the sponsor may be conducted before the completion of the study to 
ascertain data quality and integrity.  
 
The Food and Drug Administration (FDA) and/or the local state health authorities may 
request access to all study records, including source documents, for inspection. The 
investigator and site staff agree to cooperate with these audits. The investigator must 
notify the sponsor of any health authority audit as soon as notification of such audit is 
made. A representative or designee of sponsor may be present during a health authority 
audit.  
 
9. 
Amendments and deviations from the protocol 
9.1. Protocol amendments 
The protocol cannot be amended by the investigator without obtaining the sponsor’s 
approval. Protocol amendments will be submitted for approval to local IRB/EC and, if 
applicable, to the respective regulatory authority (RA). The amendments can be 
implemented in the study only after an IRB/EC and/or RA approval are obtained. Non-
substantial changes (e.g. minor logistical or administrative changes, change of 
monitor(s), telephone numbers, renewal of insurance) which do not affect the rights, 
safety and well-being of human subjects and/or are not related to the clinical investigation 
objectives or endpoints, may only require a notification to the IRB/EC and/or regulatory 
without protocol amendment. 

 
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The following documents are relevant to the protocol but are not considered part of the 
protocol.  These documents are stored and modified separately. As such, modifications 
to these documents do not require protocol amendments: 
• 
Site roster 
• 
Case report forms 
• 
Data management plan 
• 
Monitoring plan 
• 
Statistical analysis plan 
 
9.2. Protocol deviations 
A protocol deviation is any noncompliance with the clinical study protocol, Good Clinical 
Practice, or related SOPs requirements. The deviation may be associated with the 
subject, the investigator, or study personnel. The investigator/co-investigators must 
obtain the sponsor’s approval for all protocol deviations, except for cases in which the 
safety and well-being of a patient will be affected, as stated in section 4.5.4 b of the ISO 
14155 (2011).  
 
Compliance with the protocol will be assessed by the study monitor during the monitoring 
visits as well as remotely, using designated reports provided by the EDC system. 
All protocol deviations will be addressed in study subject source documents and promptly 
reported to the site IRB, according to local requirements.   
9.2.1 Procedures for recording, reporting and analyzing protocol 
deviations 
All protocol deviations will be documented in source documents and appropriate 
eCRFs. 
The study monitor is responsible for identifying and reviewing protocol deviations with 
the investigator or designee and documenting the issue and action/outcome of the 
protocol deviation in the MVR and any follow up letter/communication with the principal 
investigator. 
The study monitor will ensure that major protocol deviations are discussed with the 
investigator. Major deviations include deviations that: 
• impact patient safety  
• alter the risk/benefit ratio 
• compromise the integrity of the data  
• affect willingness of the patient’s participation in the study  
 
The deviations will be reported to the IRB/EC periodically or as specified by the local 
regulations. Further documentation of any changes in research activity should be 
submitted to the sponsor and the IRB/EC if the deviations are related to any instance 

 
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of serious or continuing non-compliance with governing regulations/requirements of the 
IRB/EC, and/or related to changes in protocol specified patient activity and procedures.  
 
In addition to the immediate reporting, the study monitor will document all deviations in 
the monitoring visit report and follow-up letters. The monitor will discuss deviations with 
relevant site personnel. If needed, a note to file will be issued and filed in the relevant 
file and a copy will be sent to the sponsor. The sponsor or its designee will review 
records of deviations and will consider the need for corrective and preventive action 
and further external reporting to regulatory authorities. Deviations will be summarized 
and included in the study report. The potential impact/lack of impact of the deviations 
on the study results will be assessed. 
 
9.3. Notification requirement and timelines 
Major deviations should be escalated to the sponsor within 5 business days. Protocol 
deviations must be reported to local IRB/EC according to their guidelines. The site PI or 
other designated site staff member is responsible for adhering to local IRB/EC 
requirements. 
 
10. Device accountability 
The devices will be provided by Theranica Bioelectronics (sponsor), with all required 
labeling. The device number will be documented in the CRF and in the site log when 
provided to the participant. Each batch of devices delivered to the clinical sites for 
allocation to study participants will be accompanied with a shipment note. The device 
shipment records will be maintained by the sponsor as well as on site. 
 
Prior to distribution, the devices will be stored in a designated locked cabinet. The access 
to the investigational devices will be controlled by the research staff. The devices will only 
be used in the clinical investigation and according to the study protocol. 
 
Each device has a sticker on it with a unique number. When a device will be provided to 
the participant, it will be paired with the participant’s smartphone using Bluetooth 
connection. During device allocation, application installation and device–smartphone 
pairing, a site allocated user ID will be entered by the study coordinator via the application.  
The three IDs (user ID, phone ID, device ID) provide a mean for identifying technical and 
PRO data from each participant in the electronic database while protecting participant’s 
privacy.  
 
The investigators will be responsible for the safe storage of the devices according to the 
instructions provided by Theranica Bioelectronics, with restricted access to the 
investigational materials in their possession, thereby preventing use of any materials by 

 
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any person not participating in the study. The device accountability records will be 
reviewed during the monitoring visits.  
 
The investigator will be responsible for providing device use training to the participants 
according to the instructions for use and protocol and for maintaining product inventory 
and records. As part of study closure, all unused devices must be returned in their original 
packaging to Theranica Bio-Electronics. 
 
 
11. Informed consent process 
Informed consent and assent must be obtained from the participant before any protocol-
related activities are performed. Participants must be provided with a signed copy of the 
consent form. The eCRFs will be updated that the informed consent form has been signed. 
  
 
12. Adverse events 
Adverse event (AE) is defined as any unfavorable and unintended medical change, 
temporally associated with the use of the sponsor’s product, whether or not considered 
related to the use of the product. Any worsening (i.e., any clinically significant adverse 
change in frequency and/or intensity) of a preexisting condition which is temporally 
associated with the use of the sponsor’s product, is also an adverse experience. An 
adverse device effect (ADE) is an adverse event related to the use of the investigational 
device. In this study the ADE refers to side effect and complications. 
 
A serious adverse event (SAE) is defined as an adverse event that leads to 
a) death,  
b) serious deterioration in the health of the subject, that either resulted in  
1) a life-threatening illness or injury, or  
2) a permanent impairment of a body structure or a body function, or  
3) in-patient or prolonged hospitalization, or  
4) medical or surgical intervention to prevent life-threatening illness or injury or 
permanent impairment to body structure or body function 
c) fetal distress, fetal death or a congenital abnormality or birth defect  
 
A serious device related adverse effect (SADE) is an adverse event related to the use of 
the investigational device and that is considered by regulations and definitions as serious. 
12.1. Characteristics of AEs 
An investigator who is a qualified physician, will evaluate all adverse events as to: 
 

 
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Maximum intensity 
Mild: awareness of symptom, but easily tolerated 
Moderate: definitely acting like something is wrong 
Severe: extremely distressed or unable to do usual activities 
 
Duration 
Record the start and stop dates of the adverse experience. If less than 1 day, indicate 
the appropriate length of time and units 
 
Relationship of an AE and SAE to the study device  
The relationship of the adverse event to the study device is defined as: 
 
Definitely related: There is evidence of exposure to the device. The temporal sequence 
of the AE onset relative to use of the device is reasonable. The AE is more likely 
explained by the device than by another cause. Dechallenge is positive. Rechallenge (if 
feasible) is positive. The AE shows a pattern consistent with previous knowledge of the 
device.  
Probably related: There is evidence of exposure to the device. The temporal sequence 
of the AE onset relative to use of the device is reasonable. The AE is more likely 
explained by the device than by another cause. Dechallenge (if performed) is positive.  
Possibly related: There is evidence of exposure to the device. The temporal sequence 
of the AE onset relative to use of the device is reasonable. The AE could have been due 
to another equally or less likely cause. Dechallenge (if performed) is positive. 
Definitely not related: The subject/patient did not use the device; or temporal sequence 
of the AE onset relative to device use is not reasonable; or there is another obvious 
cause of the AE. 
12.2. Reporting of AEs and SAEs 
All adverse events will be recorded in appropriate adverse events case report form. The 
adverse events will be used for the safety assessment. An on-site visit to monitor the 
adverse event will be conducted if the principal investigator determines it is needed. 
These visits will be reported using designated case report forms. If during the last visit, 
an ongoing device-related AE is present, the participant will be monitored for 
approximately 2 weeks, until the AE resolves or a steady state is achieved.   
 
The PI must report any SAE or SADE to the sponsor within 1 business day: 
Theranica Bioelectronics  
Dr. Dagan Harris 
Tel: +972.72.390.9758 

 
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Fax: + 972.72.390.9755 
Email: daganh@theranica.com 
 
The sponsor is responsible for reporting the adverse events to regulatory agencies, 
IRB/IECs, and investigators in accordance with all applicable global laws and 
regulations. 
 
12.3. Anticipated device-related AEs 
Possible adverse events associated with remote electrical neuromodulation include, but 
are not limited to, the following: 
• 
Numbness of the hand/arm 
• 
Itching 
• 
Muscle spasms 
• 
Redness 
• 
Warmth sensation 
• 
Tingling 
• 
Pain in the arm 
 
All anticipated devoice-related AEs, if present, are temporary and should disappear 
shortly after the treatment. 
The following migraine symptoms are foreseeable and will not be considered as device 
related: headache, nausea, light sensitivity, sensitivity to noise, allodynia, abdominal 
pain, loss of appetite, cold or heat sensation, paleness, fatigue, dizziness, anxious mood, 
fever (rare), blurred vision, vision symptoms such as bright flashing dots or lights, blind 
spots, wavy or jagged lines (aura). 
 
12.4. Device malfunction 
Device malfunction is an inadequacy of the device with respect to its identity, quality, 
durability, reliability, safety, or performance, such as failure, use error or inadequate 
labeling. Device malfunctions may or may not be associated with an adverse event.  
All device malfunctions will be reported in the eCRF. Device malfunctions that were 
associated with an SAE or that could have led to an SAE if a) suitable action had not 
been taken or b) intervention had not been made or c) if circumstance had been less 
fortunate, will be reported within 24 hours of occurrence. If possible and needed, the 
device(s) associated with malfunction or failure will be retained until arrangements for its 
collection are made by the sponsor. 
 
All device malfunctions will be summarized and reported in the clinical study report and 
will be reported to the regulatory authorities according to local reporting requirements. 
 
 

 
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13. Early termination 
13.1 
Criteria and procedures 
The study may be discontinued if: 
 
The sponsor decides to terminate the study due to company considerations (e.g. the 
data monitoring committee recommends terminating the study based on the interim 
analysis)  
 
If in the opinion of study PI, the study presents an unreasonable medical risk to the 
patients, the PI may close the site under his/her responsibility. 
 
If the clinical investigation terminated early or suspended, the sponsor will send a report 
justifying this decision to the corresponding IRB/EC, regulatory body and all 
investigators. A suspended or terminated clinical investigation may not be re-initiated 
without approval of the corresponding IRB/EC and relevant RA, as applicable. Enrolled 
subjects will be followed according to the institution’s standards and guidelines. 
 
13.2 
Requirements for patient follow-up in case of withdrawal 
If a patient withdraws consent, all efforts will be made to collect the final visit observations 
as soon as possible. 
 
 
14. Publication policy 
The publication policy is defined in the sponsor-investigator agreement. 
 
 
15. Patient confidentiality & data protection 
The privacy of the participants and the confidentiality of all personal data will be 
maintained in reports and publications and will not be otherwise published in any way. 
The privacy will be maintained according to prevailing national data protection, privacy 
and secrecy laws. Each patient will be identified by a unique patient identification number. 
However, the sponsor’s monitor or representative and regulatory representatives, auditors 
and inspectors may have access to medical files in order to verify the authenticity of the 
data collected, as documented in the informed consent form. 
 
 
16. Guidelines and applicable documents 
• 
EN ISO 14155; (2011): Clinical investigation of medical devices for human patients  

 
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• 
EN ISO 14971; (2012): Medical devices – Application of risk management to medical 
devices 
• 
International Conference of Harmonization Good Clinical Practice guidelines 
• 
FDA Guidance for Industry: Computerized Systems Used in Clinical Investigations 
 
 
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