Headache and Pain Research

Review Article

Morning Headaches: An In-depth Review of Causes, Associated Disorders, and Management Strategies: Yooha Hong, Mi-Kyoung Kang, Min Seung Kim, Heejung Mo, Rebecca C. Cox, Hee-Jin Im; Received August 4, 2024 Accepted September 30, 2024 Published online January 17, 2025; DOI: https://doi.org/10.62087/hpr.2024.0023 [Epub ahead of print]

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Abstract PDF: Morning headaches, which are defined by occurrence upon or shortly after waking up in the morning, range from mild discomfort to severe pain and significantly impact an individual’s quality of life. Although morning headaches are a prevalent and potentially debilitating condition, the criteria for defining these headaches vary. The lack of universally accepted diagnostic criteria complicates understanding their etiology, associated factors, and potential interventions. The causes of morning headaches are multifaceted, including primary headache disorders like migraines and cluster headaches, and secondary causes such as sleep disorders, hypertension, abnormal intracranial pressure, and brain parenchymal diseases. Psychological factors, including anxiety and depression, as well as substance use, further complicate the clinical presentation, often requiring a multidisciplinary approach for effective diagnosis and treatment. This review provides a comprehensive overview of morning headaches, examining their various aspects and possible treatment options, with the goal of enhancing clinicians’ understanding and management of this common yet often overlooked condition.

Original Article

Evidence-Based Recommendations on Pharmacologic Treatment for Migraine Prevention: A Clinical Practice Guideline from the Korean Headache Society: Byung-Su Kim, Pil-Wook Chung, Jae Myun Chung, Kwang-Yeol Park, Heui-Soo Moon, Hong-Kyun Park, Dae-Woong Bae, Jong-Geun Seo, Jong-Hee Sohn, Tae-Jin Song, Seung-Han Lee, Kyungmi Oh, Mi Ji Lee, Myoung-Jin Cha, Yun-Ju Choi, Miyoung Choi; Received June 23, 2024 Accepted September 11, 2024 Published online January 16, 2025; DOI: https://doi.org/10.62087/hpr.2024.0019 [Epub ahead of print]

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Abstract PDF: Purpose: The aim of this clinical practice guideline (CPG) from the Korean Headache Society is to provide evidence-based recommendations on the pharmacologic treatment for migraine prevention in adult migraine patients.
Methods
The present CPG was developed based on the guideline adaptation methodology through a comprehensive systematic search for literature published between January 2012 and July 2020. The overall quality of the CPGs was assessed using the Korean version of the Appraisal of Guidelines for Research and Evaluation II tool. High-quality CPGs were adapted to make key recommendations in terms of strength (strong or weak) and direction (for or against).
Results
The authors selected nine available high-quality guidelines throughout the process of assessment of quality. Regarding oral migraine preventive medications, propranolol, metoprolol, flunarizine, sodium divalproex, and valproic acid are recommended to adult patients with episodic migraines based on high-quality evidence (“strong for”). Topiramate can be recommended for either episodic or chronic migraine (“strong for”). For migraine prevention using calcitonin gene-related peptide monoclonal antibodies, galcanezumab, fremanezumab, erenumab, and eptinezumab are recommended for adult patients with either episodic or chronic migraine on the basis of high-quality evidence (“strong for”). OnabotulinumtoxinA is recommended for adult patients with chronic migraine based on high-quality evidence (“strong for”). Last, frovatriptan, naratriptan, and zolmitriptan are recommended for short-term prevention in women with menstrual migraine (“strong for”).
Conclusion
In the present CPG, the authors provide specific, straightforward, and easy-to-implement evidence-based recommendations for pharmacologic migraine prevention. Nevertheless, these recommendations should be applied in real-world clinical practice based on optimal individualization.

Review Article

Update on Tension-type Headache: Hye Jeong Lee, Soo-Jin Cho, Jong-Geun Seo, Henrik Winther Schytz; Received September 7, 2024 Accepted October 4, 2024 Published online December 30, 2024; DOI: https://doi.org/10.62087/hpr.2024.0025 [Epub ahead of print]

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Abstract PDF: Tension-type headache (TTH) is the most common type of headache, characterized by mild to moderate intensity, bilateral, with a pressing or tightening (non-pulsating) quality. Migraine and TTH can occur in the same person, and their risk factors and treatments can overlap. However, TTH receives less attention than migraine. Furthermore, despite the expanding market for migraine treatments targeting calcitonin gene-related peptide (CGRP) mechanisms, the lack of evidence regarding mechanisms related to CGRP-related mechanisms in TTH continues to be neglected. There remains a need to develop effective preventive treatments for chronic TTH, which imposes a very high burden of disease. From this perspective, this review aims to provide the latest evidence on TTH.

Editorial

Nutritional Approaches to Managing Pediatric Migraine: Hye Eun Kwon; Headache Pain Res. 2024;25(2):75-76. Published online October 24, 2024; DOI: https://doi.org/10.62087/hpr.2024.0027

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Original Articles

Subjective Cognitive Decline Patterns in Patients with Migraine, with or without Depression, versus Non-depressed Older Adults: Sun Hwa Lee, Soo-Jin Cho; Headache Pain Res. 2024;25(2):103-110. Published online October 24, 2024; DOI: https://doi.org/10.62087/hpr.2024.0022

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Abstract PDF: Purpose: Cognitive decline is a common complaint in young patients with migraine, especially those with depression. Independent of psychiatric factors such as depression, subjective cognitive decline (SCD) is associated with an elevated risk of progression to dementia. This study aimed to investigate patterns of subjective cognitive complaints between migraineurs with or without depression and non-depressed older adults.
Methods
This retrospective study included 331 outpatients with SCD (293 from a headache clinic and 38 from a memory clinic). SCD was diagnosed as “yes” based on two questions about SCD. The Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were used to assess cognitive function. The SCD Questionnaire (SCD-Q) with three subdomains was analyzed to compare SCD between groups.
Results
Among patients with SCD, significant differences in duration of education were found among the groups—specifically, migraineurs with depression (12.39 years) had longer education than non-depressed older adults (10.50 years) and shorter education than migraineurs without depression (14.28 years). The total MMSE and MoCA scores did not differ between migraineurs with and without depression. Regarding SCD-Q scores, migraineurs with depression showed higher scores overall and in all cognitive domains than migraineurs without depression, with no significant difference compared to non-depressed older adults.
Conclusion
Although the depressed migraineurs with SCD were younger and more educated than the non-depressed older adults with SCD, both groups reported similarly high levels of SCD. Higher levels of surveillance for cognitive decline are warranted for migraineurs with depression who have SCD.

Bilateral Greater Occipital Nerve Block for Preventing the OnabotulinumtoxinA Wear-off Phenomenon in the Treatment of Chronic Migraine: A Case Series of 12 Patients: Sanghyun Kim, Jae Young An, Dae Woong Bae; Headache Pain Res. 2024;25(2):111-116. Published online October 23, 2024; DOI: https://doi.org/10.62087/hpr.2024.0021

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Abstract PDF

Purpose: OnabotulinumtoxinA is widely used to treat chronic migraines; however, the wear-off phenomenon before the next scheduled dose has emerged as a challenge. This study suggests a new strategy for preventing the wear-off phenomenon using bilateral greater occipital nerve block.
Methods
We conducted a retrospective review of patients diagnosed with chronic migraine who were treated with onabotulinumtoxinA and bilateral greater occipital nerve block at St. Vincent Hospital from January 2023 to December 2023. Twelve chronic migraine patients with a history of the wear-off phenomenon received a greater occipital nerve block 8 weeks after the initial onabotulinumtoxinA injection for two sessions. Responses to treatment were evaluated with regular follow-ups and daily headache diaries.
Results
All patients who had previously experienced the wear-off phenomenon with conventional onabotulinumtoxinA treatment did not experience the wear-off phenomenon during two sessions with an additional greater occipital nerve block administered 8 weeks after each onabolulinumtoxinA injection.
Conclusion
Bilateral greater occipital nerve block administered 8 weeks after the initial onabotulinumtoxinA injection effectively prevents the wear-off phenomenon, enabling sustained therapeutic benefits in chronic migraine patients. Further research is needed to confirm these findings in larger cohorts.

Citations

Citations to this article as recorded by

When Should Headache Specialists Hold a Needle? The Role of Botulinum Toxin Injections and Occipital Nerve Blocks
Soo-Jin Cho
Headache and Pain Research.2024; 25(2): 73. CrossRef

Editorial

When Should Headache Specialists Hold a Needle? The Role of Botulinum Toxin Injections and Occipital Nerve Blocks: Soo-Jin Cho; Headache Pain Res. 2024;25(2):73-74. Published online October 17, 2024; DOI: https://doi.org/10.62087/hpr.2024.0020

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Case Report

Mechanical Thrombectomy in Cerebral Venous Thrombosis Caused by Spontaneous Intracranial Hypotension: A Case Report with Novel Pathological Findings of Fibrin/Platelet-predominant Thrombus: Min Kyoung Kang, Eun Young Kim, Hye-Rim Shin; Headache Pain Res. 2024;25(2):122-127. Published online October 2, 2024; DOI: https://doi.org/10.62087/hpr.2024.0016

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Abstract PDF: This case report presents pathological findings in a rare case of cerebral venous thrombosis (CVT) caused by spontaneous intracranial hypotension (SIH) that was treated successfully with mechanical thrombectomy. The etiologies and prognosis of CVT vary, and CVT resulting from SIH is particularly uncommon and challenging to diagnose and manage. In this case, magnetic resonance imaging revealed signs consistent with both SIH and CVT, which contributed to the patient’s worsening weakness. The patient was treated with a combination of endovascular thrombectomy and epidural blood patch, followed by anticoagulation therapy, and recovered without any complications. A pathological analysis of the retrieved thrombus using hematoxylin and eosin staining showed a high proportion of fibrin and platelets, which could shed light on the mechanism of CVT induced by SIH under conditions of low blood flow due to venous engorgement.

Review Article

Advances in Primary Stabbing Headache: Diagnostic Criteria, Epidemiological Insights, and Tailored Treatment Approaches: Ayush Chandra, Avinash Chandra, Soohyun Cho; Received June 8, 2024 Accepted July 3, 2024 Published online September 2, 2024; DOI: https://doi.org/10.62087/hpr.2024.0018 [Epub ahead of print]

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Abstract PDF: Primary stabbing headache (PSH), characterized by sudden, localized stabbing headache pain, is a recognized primary headache disorder with evolving diagnostic criteria. Epidemiological studies show a wide range of prevalence, influenced by various factors. PSH is more common in females, frequently occurring in conjunction with migraine, and can manifest in children. Recent diagnostic criteria have changed the definition of sharp stabbing pain, which is no longer restricted to the first division of the trigeminal nerve. In addition, the criterion of “no accompanying symptoms” has been refined to “no cranial autonomic symptoms” specifically. These changes have increased the sensitivity for capturing PSH. Although it is generally considered benign, stabbing headache can be associated with secondary causes. Clinical red flag signs can be helpful in distinguishing secondary headaches from PSH. A recent prospective study has proposed the monophasic, intermittent, and chronic patterns as subtypes, and this division may be helpful for predicting the prognosis. Pharmacological treatment is typically not required for PSH, although indomethacin and other alternating agents can be used. The treatment should be selected based on individual clinical features and comorbidities. This review aims to highlight the necessity of recognizing the distinctive clinical profile of PSH and of tailoring treatment approaches to patients’ individual needs.

Case Report

Primary Headache Associated with Sexual Activity Presenting with Persistent Genital Arousal Disorder: A Case Report: Woo-Seok Ha, Hye-Kyung Baek; Headache Pain Res. 2024;25(2):117-121. Published online September 2, 2024; DOI: https://doi.org/10.62087/hpr.2024.0012

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Abstract PDF: Persistent genital arousal disorder (PGAD) is characterized by unwanted and distressing genital sensations that are not associated with concomitant sexual interest or thoughts. Several etiologies have been proposed, but the underlying mechanism of the condition remains unclear. In this report, we describe a case of PGAD presenting with primary headache associated with sexual activity (PHASA). A 57-year-old female with no history of headache experienced recurrent, unwanted episodes of genital arousal lasting 3 to 5 days for 4 years. One day, she began to experience intense genital arousal that she had never experienced before. On the fourth day of arousal, while attempting intercourse with her partner, she experienced an abrupt explosive headache, which was repeated during another session of intercourse a week later. The patient underwent laboratory tests, as well as brain magnetic resonance imaging (MRI) and magnetic resonance angiography, all of which showed normal findings. She was referred to a sexual medicine specialist and prescribed amitriptyline, escitalopram, and propranolol with a diagnosis of PGAD. Her sexual arousal gradually diminished, and when she stopped all medications 3 months later, all symptoms had disappeared. On further investigation, spinal MRI revealed a Tarlov cyst. She has been in remission for three years. This case illustrates the co-occurrence of PHASA and PGAD and suggests a possible common pathophysiology shared between these two rare disorders.

Original Article

Side Shift of Attacks in Cluster Headache: A Prospective Single-center Study: Michelle Sojung Youn, Jun Pyo Kim, Mi Ji Lee; Headache Pain Res. 2024;25(2):96-102. Published online August 28, 2024; DOI: https://doi.org/10.62087/hpr.2024.0013

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Abstract PDF: Purpose: Although strict unilaterality is a characteristic of cluster headache (CH), side shift of attacks has been reported. We aimed to assess the prevalence and patterns of side shifts, as well as their correlations with clinical characteristics and treatment response in CH patients.
Methods
We prospectively recruited and followed up CH patients at a university hospital. Patients with two or more lifetime CH bouts were interviewed about their side shift history using a structured questionnaire. The demographics and disease characteristics were collected at baseline, and the treatment response at 2- to 4-week follow-up examinations was compared between patients with versus without side shifts.
Results
Out of 124 CH patients, 26 (21.0%) experienced side shifts. Sixteen (61.5%) experienced shifts between bouts, 13 (50.0%) within a bout, and four (15.4%) within an attack, with none (0%) reporting bilateral pain during an attack. Among patients who experienced shifts between bouts, six (37.5%) reported a single shift during the entire disease course, while 10 (62.5%) reported multiple shifts between bouts. The demographics, characteristics, and treatment response did not significantly differ according to the history of side shift.
Conclusion
In our study, the prevalence and pattern of side shifts were comparable to the results from earlier studies. The presence of side shifts did not show significant association with a specific clinical profile and their incidence did not impact the treatment response. These findings suggest that side-shifting CH is not a distinct entity or migraine variant, but rather within the spectrum of CH.

Review Articles

Understanding the Connection between the Glymphatic System and Migraine: A Systematic Review: Myoung-Jin Cha, Kyung Wook Kang, Jung-won Shin, Hosung Kim, Jiyoung Kim; Headache Pain Res. 2024;25(2):86-95. Published online July 31, 2024; DOI: https://doi.org/10.62087/hpr.2024.0014

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Abstract PDF: The glymphatic system is a brain-wide perivascular pathway that functions similarly to the lymphatic system in the periphery of the body, playing a crucial role in removing waste from the brain. Although impaired glymphatic function has a well-known relationship with neurodegenerative diseases through abnormal protein accumulation, it is also associated with migraine. While still in its nascent phase, research on the glymphatic system in migraine patients is gradually increasing. This systematic literature review focuses on studies investigating the glymphatic system in migraineurs. Furthermore, it examines the methods used to evaluate the glymphatic system in these studies and their main findings.

What a Neurologist Should Know about Functional Anatomy for Botulinum Toxin Injections in the Head, Face, and Neck: A Practical Perspective: So Ra Kim, Vittorio Favero, Alec Hyung Kim, SeongTaek Kim; Headache Pain Res. 2024;25(2):77-85. Published online July 22, 2024; DOI: https://doi.org/10.62087/hpr.2024.0005

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Abstract PDF

Since botulinum toxin (BoNT) was approved by the US Food and Drug Administration as a prophylactic treatment for chronic migraines in 2010, subsequent studies have shown that BoNT is effective in the management of chronic migraines due to its pain-relieving effects. Therefore, neurologists are increasingly utilizing BoNT as a therapeutic tool for chronic migraine. It is crucial to thoroughly understand the functional anatomy in the head, face, and neck regions to successfully administer BoNT injections in these areas. This review describes the complexity of muscles and their associated target nerves in the frontal, temporal, and occipital areas and serves as a resource for essential functional anatomy, with the goal of providing clinicians with a practical perspective on utilizing BoNT injections.

Citations

Citations to this article as recorded by

When Should Headache Specialists Hold a Needle? The Role of Botulinum Toxin Injections and Occipital Nerve Blocks
Soo-Jin Cho
Headache and Pain Research.2024; 25(2): 73. CrossRef

Editorial

Migraine in Women: Inescapable Femaleness?: Soo-Kyoung Kim; Headache Pain Res. 2024;25(1):1-2. Published online April 24, 2024; DOI: https://doi.org/10.62087/hpr.2024.0010

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Review Article

Update on Cluster Headaches: From Genetic to Novel Therapeutic Approaches: Myun Kim, Je Kook Yu, Yoo Hwan Kim; Headache Pain Res. 2024;25(1):42-53. Published online April 22, 2024; DOI: https://doi.org/10.62087/hpr.2024.0009

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3 Citations

Abstract PDF

Cluster headaches affect 0.1% of the population and are four times more common in males than in females. Patients with this condition present with severe unilateral head pain localized in the frontotemporal lobe, accompanied by ipsilateral lacrimation, conjunctival injection, nasal congestion, diaphoresis, miosis, and eyelid edema. Recently, the first genome-wide association study of cluster headaches was conducted with the goal of aggregating data for meta-analyses, identifying genetic risk variants, and gaining biological insights. Although little is known about the pathophysiology of cluster headaches, the trigeminovascular and trigeminal autonomic reflexes and hypothalamic pathways are involved. Among anti-calcitonin gene-related peptide monoclonal antibodies, galcanezumab has been reported to be effective in preventing episodic cluster headaches.

Citations

Citations to this article as recorded by

Side Shift of Attacks in Cluster Headache: A Prospective Single-center Study
Michelle Sojung Youn, Jun Pyo Kim, Mi Ji Lee
Headache and Pain Research.2024; 25(2): 96. CrossRef
Reduction of neck pain severity in patients with medication-overuse headache
Yooha Hong, Hong-Kyun Park, Mi-Kyoung Kang, Sun-Young Oh, Jin-Ju Kang, Heui-Soo Moon, Tae-Jin Song, Mi Ji Lee, Min Kyung Chu, Soo-Jin Cho
The Journal of Headache and Pain.2024;[Epub] CrossRef
Exercise as an abortive treatment for cluster headaches: Insights from a large patient registry
Mi‐Kyoung Kang, Yooha Hong, Soo‐Jin Cho
Annals of Clinical and Translational Neurology.2024;[Epub] CrossRef

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