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 answer the questions below as completely as you can — your responses will help our team determine whether TEMMA or another treatment option is appropriate for you.

Your Information

First Name *

Last Name *

Date of Birth *

Cell Phone *

State

Average Number of Migraine Headaches Per Month

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

What medications have you tried for your migraines?

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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