TEMMA Migraine Questionnaire

Tell us about your migraines to see if TEMMA may be right for you.

To be considered for the TEMMA procedure (an emerging option for severe refractory migraines), please carefully follow the instructions in each question — your accurate responses will determine if further evaluation is appropriate.

Your Information

First Name *

Last Name *

Date of Birth *

Cell Phone *

State *

⚠️ To be considered for TEMMA, you must select "8 or more headache days per month" — lower frequencies do not meet the current criteria.

Average Number of Migraine Headaches Per Month *

⚠️ You must select at least one associated symptom — none selected does not meet the current criteria for TEMMA.

What associated symptoms do you have with your migraines? *

Visual Changes (e.g., flashing lights, zigzag lines, blind spots, or temporary vision loss)Numbness, tingling, or sensory changes (especially on one side of the face, arm, or leg)Weakness or paralysis (especially on one side of the body)Speech difficulties (e.g., slurred speech, trouble finding words, or understanding others)Dizziness, vertigo, loss of balance, or coordination issuesConfusion, brain fog, difficulty concentrating, or trouble thinking clearly

⚠️ You must select at least two categories of preventive medications that failed due to inadequate relief, intolerable side effects, or contraindications — fewer than two does not meet the current criteria for TEMMA.

What medications have you tried for your migraines? (must select at least 2) *

Beta-blockers (e.g., propranolol, metoprolol, timolol)Anticonvulsants/Anti-epileptics (e.g., topiramate, valproate)Antidepressants (e.g., amitriptyline, venlafaxine)CGRP monoclonal antibodies (e.g., erenumab/Aimovig, fremanezumab/Ajovy)OnabotulinumtoxinA (Botox) or other injectablesOther preventive medications (e.g., calcium channel blockers, candesartan, memantine, gabapentin, supplements)

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