Individualized Location-based rTMS for Migraine Treatment: A Multicenter Clinical Study

A migraine day: any calendar day in which the participant experienced a qualified migraine headache (onset, continuation, or recurrence of the migraine headache). A qualified migraine headache: a migraine with or without aura, lasting for ≥30 minutes, and meeting at least 1 of the following criteria (a and/or b): a) ≥2 of the following: unilateral location, pulsating quality, moderate to severe pain intensity, aggravation by or causing avoidance of routine physical activity; b) ≥1 of the following: nausea and/or vomiting, photophobia, and phonophobia. If the participant took a migraine-specific medication during aura or to treat headache on a calendar day, it was counted as a migraine day regardless of the duration and pain features/associated symptoms.

A migraine day was any calendar day in which the participant experienced a qualified migraine headache (as previously described). If the participant took a migraine-specific medication during aura or to treat headache on a calendar day, it was counted as a migraine day regardless of the duration and pain features/associated symptoms. A moderate or severe migraine day was a migraine day of moderate or severe pain intensity. Months were defined as 28-day intervals.

The Migraine Disability Assessment (MIDAS) is a retrospective, self-administered, 5-item questionnaire that measures headache-related disability as lost time due to headache from paid work or school, household work, and non-work activities. Participants provide the number of missed work or school days; missed household chores days; missed social or leisure activity days; and days at work or school, and separately at home, where productivity was reduced by half or more in the last 3 months (scale: 0 - 90 for each of 5 subscales). The 5 subscale scores are summed to compute the MIDAS total score (scale: 0 - 450). Lower scores indicate less headache-related disability.

The Migraine Specific Quality of Life (MSQoL) is a self-administered, 14-item instrument that has been validated in 3 domains: role restriction, role prevention, and the emotional function. The role function-restrictive domain consists of 7 items that describe how migraine limits one's daily social and work-related activities. Participants respond to items using a 6-point scale: "none of the time," "a little bit of the time," "some of the time," "a good bit of the time," "most of the time," and "all of the time," which are assigned scores of 1 to 6, respectively. Item scores are recoded using (7 - original score). Next, raw dimension scores are computed as a sum of recoded item scores and rescaled from a 0 to 100 scale such that higher scores indicate better quality of life.

HIT-6 (Headache Impact Test-6) for Migraine: The HIT-6 is a widely used tool to assess the impact of headaches on a patient's quality of life. It consists of 6 questions, each rated on a 5-point scale ranging from "Never" to "Always." The total score is obtained by summing the individual item scores, with a higher score indicating a greater impact of migraine on the patient's daily functioning. A decrease in the HIT-6 score from baseline indicates an improvement in the patient's condition and a reduction in the impact of migraines on their life.

PSQI (Pittsburgh Sleep Quality Index) for Sleep: The PSQI is a validated questionnaire used to assess the quality and patterns of sleep in the past month. It includes 19 items across 7 component areas: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. Each component is scored on a 0 to 3 scale, and the total score ranges from 0 to 21, with higher scores indicating poorer sleep quality. A decrease in the PSQI score from baseline indicates an improvement in sleep quality.

PGIC (Patient Global Impression of Change): The PGIC is a single-item scale used to assess the patient's overall perception of change in their condition over time. The patient rates their perceived change in symptoms or overall health since the start of the study or treatment on a 7-point scale, where:

• = Very Much Improved
• = Much Improved
• = Minimally Improved
• = No Change
• = Minimally Worse
• = Much Worse
• = Very Much Worse

A higher score indicates a negative change in the patient's condition, while a lower score indicates improvement. The mean change from baseline reflects the overall perceived improvement or worsening of the patient's condition during the study period.

HAMD-24 (Hamilton Depression Rating Scale, 24-item): The HAMD-24 is a clinician-administered scale used to assess the severity of depressive symptoms. It consists of 24 items, with each item scored on a 3 to 5-point scale based on the severity of the symptom (e.g., 0 = not present, 1 = mild, 2 = moderate, 3 = severe). The total score is calculated by summing the individual item scores, with higher scores indicating more severe depression. A reduction in the HAMD-24 score from baseline indicates improvement in the severity of depressive symptoms.

HAMA-14 (Hamilton Anxiety Rating Scale, 14-item): The HAMA-14 is a clinician-administered scale used to assess the severity of anxiety symptoms. It includes 14 items that cover both psychic and somatic aspects of anxiety, such as tension, fear, insomnia, and somatic symptoms (e.g., gastrointestinal distress, dizziness). Each item is rated on a 5-point scale ranging from 0 (not present) to 4 (severe). The total score is calculated by summing the individual item scores, with higher scores indicating greater severity of anxiety. A reduction in the HAMA-14 score from baseline indicates a decrease in anxiety symptoms.

Tryptophan and Kynurenine:

Measurement Method: Liquid Chromatography-Mass Spectrometry (LC-MS) or High-Performance Liquid Chromatography (HPLC) with UV detection.

Units: µmol/L or nmol/mL.

CGRP (Calcitonin Gene-Related Peptide), PACAP (Pituitary Adenylate Cyclase-Activating Polypeptide), VIP (Vasoactive Intestinal Peptide), NPY (Neuropeptide Y), Substance P, Endothelin-1:

Measurement Method: Enzyme-Linked Immunosorbent Assay (ELISA), Radioimmunoassay (RIA), or Luminex xMAP technology.

Units: pg/mL or ng/mL.

Inflammatory Factors (IL-1β, IL-6, TNF-α, TGF-β1):

Measurement Method: ELISA. Units: pg/mL or ng/mL.

Glutamate:

Measurement Method:High-Performance Liquid Chromatography (HPLC) with fluorescence detection or LC-MS/MS.

Units:µmol/L or nmol/mL.

Endocannabinoids:

Measurement Method:Liquid Chromatography-Mass Spectrometry (LC-MS) or Gas Chromatography-Mass Spectrometry (GC-MS).

Units: pg/mL or nmol/L.

Related Lipids:

Measurement Method: LC-MS/MS or Gas Chromatography-Mass Spectrometry (GC-MS). Units:ng/mL or µg/mL.

Gut Microbiota:

Measurement Method: 16S rRNA Gene Sequencing (Next-Generation Sequencing, NGS) or Metagenomic Sequencing.

Units: Relative abundance (percentage of total microbiota composition) or Operational Taxonomic Unit (OTU) counts.

Resting-State fMRI (rs-fMRI): This imaging technique assesses brain activity in the absence of an explicit task. It measures spontaneous fluctuations in the blood oxygen level-dependent (BOLD) signal, which is an indicator of neural activity.

Analysis Focus:The primary focus is on pain-related brain regions such as the somatosensory cortex, anterior cingulate cortex (ACC), insula, thalamus, and prefrontal cortex , as well as changes in the functional connectivity between these regions.

Connectivity Analysis:Functional connectivity will be evaluated by examining seed-based analysis or independent component analysis (ICA) to identify altered networks related to pain processing and perception.