Headache and Pain Research

Original Articles

Early Development of Spinal Cord Herniation in Spontaneous Intracranial Hypotension: Seung Ae Kim, Soyoun Choi, Kyunghoon Yang, Hye Jin Yoo, Ja-Young Choi, Mi Ji Lee; Headache Pain Res. 2026;27(3):231-240. Published online October 30, 2026; DOI: https://doi.org/10.62087/hpr.2026.0043

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Abstract PDF: Purpose: Spinal cord herniation has been recognized as a very rare, late complication of spontaneous intracranial hypotension (SIH). This study examined the incidence and timing of early spinal cord herniation in SIH and the factors associated with its development.
Methods
Data from a prospective cohort of patients with SIH at Seoul National University Hospital (2022–2024) were analyzed retrospectively. Eligible patients presented within 1 year of symptom onset, had a spinal longitudinal epidural collection, and had no spinal cord herniation at baseline. Kaplan–Meier analysis was used to estimate the cumulative incidence of spinal cord herniation, and Cox regression was used to evaluate risk factors.
Results
The study included 92 patients with SIH who presented within 1 year of onset (mean age, 40.6 years; 39.1% male). Spinal cord herniation was first detected in eight patients, a mean of 174.1±180.5 days after symptom onset. Its cumulative incidence reached 10.3% by 1 year and 14.2% by 2 years.
Conclusion
In patients presenting within 1 year of symptom onset with a type 1 leak, spinal cord herniation may develop earlier than previously recognized, even without neurological symptoms. Careful follow-up is essential to ensure timely, appropriate management. Caution is warranted, however, when generalizing these incidence estimates to the overall SIH population.

Feasibility and Safety of Elexir, an External Trigeminal Nerve Electrical Stimulator for the Acute Treatment of Migraine: Soo-Im Jang, Soohyun Cho, Mi Ji Lee; Headache Pain Res. 2026;27(3):193-203. Published online October 30, 2026; DOI: https://doi.org/10.62087/hpr.2026.0041

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Abstract PDF Supplementary Material: Purpose: External trigeminal nerve stimulation (eTNS) is a noninvasive neuromodulation technique used to treat migraine. This study evaluated the feasibility and safety of Elexir®, a newly developed eTNS device, for the acute treatment of migraine at home.
Methods
This prospective, randomized, sham-controlled postmarketing study enrolled participants with migraine who reported 2–8 attacks per month. Participants were assigned 1:1 to verum or sham stimulation and instructed to use Elexir® at home for 60 minutes during an eligible migraine attack. Feasibility of home use was assessed in terms of per-protocol use and treatment completion at both the participant and session levels; session completion was defined by 60 (±5)-minute stimulation recorded in the device log. Assessments also included adverse events (AEs) and exploratory efficacy outcomes: changes in pain intensity, pain freedom and relief, and resolution of associated symptoms.
Results
Of the 100 randomized participants, 79 formed the home-use population. Within this population, 78 (98.7%; 95% confidence interval [CI], 93.2%–99.8%) used Elexir® during an eligible migraine attack, and 75 (94.9%; 95% CI, 87.7%–98.0%) completed at least one session. Of the 139 treatment sessions conducted at home, 103 (74.1%; 95% CI, 66.2%–80.7%) were completed within the protocol-defined duration. Ten participants (10.0%) reported AEs and eight participants (8.0%) reported device-related AEs. No serious device-related AEs were observed. The groups did not differ significantly in exploratory efficacy outcomes.
Conclusion
These findings support the feasibility of using Elexir® for the acute treatment of migraine; no serious device-related AEs were observed. Further studies are required to support efficacy.

Case Report

Spontaneous Intracranial Hypotension Masquerading as Headache from an Unruptured Middle Cerebral Artery Aneurysm: Myoung-Jin Cha, Jiyoung Kim; Headache Pain Res. 2026;27(3):241-245. Published online October 30, 2026; DOI: https://doi.org/10.62087/hpr.2026.0040

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Abstract PDF: Spontaneous intracranial hypotension (SIH) is characterized by neurological symptoms resulting from cerebrospinal fluid leakage or volume depletion. Although orthostatic headache is the hallmark symptom, SIH can also present with nausea, vomiting, dizziness, tinnitus, and other neurological symptoms. In this case, a cerebral aneurysm identified during evaluation of the headache was initially considered a potential cause, prompting a decision to treat it. However, an orthostatic headache severe enough to interfere with standing or physical activity had been overlooked. After a pre-existing subdural effusion was identified, the evolving orthostatic features of the headache and the imaging findings raised suspicion of SIH. The headache resolved after a lumbar epidural blood patch. Although a cerebral aneurysm is a potential cause of headache, SIH may be difficult to recognize early. Careful history taking, particularly about the characteristics and postural nature of the headache, is therefore essential to appropriately evaluate patients with headache.

Original Article

Dynamic Changes in Interictal Burden During 3-Year Follow-Up for Medication Overuse Headache: Yooha Hong, Mi-Kyoung Kang, Soo-Jin Cho; Headache Pain Res. 2026;27(3):211-220. Published online October 30, 2026; DOI: https://doi.org/10.62087/hpr.2026.0039

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Abstract PDF: Purpose: Treatment improves medication overuse headache (MOH), but interictal burden may persist. Limited longitudinal data leave uncertainty about whether residual burden reflects persistent impairment, recovery, or newly emerging burden. We investigated changes in interictal burden during the 3 years after MOH diagnosis.
Methods
This single-center substudy of a nationwide prospective MOH registry enrolled 149 patients at baseline and assessed interictal burden at the 2- and 3-year follow-ups using the 4-item Migraine Interictal Burden Scale (MIBS-4). The Wilcoxon signed-rank test and exact McNemar test were used to analyze paired changes.
Results
At 3 years, clinical follow-up was completed by 89 patients and the MIBS-4 by 61; 57 had paired assessments at 2 and 3 years. At this follow-up, 9 of 89 patients (10.1%) had medication overuse (MO). Among patients with paired MIBS-4 assessments, the median score decreased from 2.0 (0.0–4.0) at 2 years to 1.0 (0.0–3.0) at 3 years (p=0.006), and the proportion with substantial-to-severe interictal burden decreased from 47.4% to 29.8% (p=0.031). Recurrence by 3 years affected 8.3% of patients whose MO had resolved at 2 years. At 3 years, substantial-to-severe interictal burden persisted in 28.6% of patients whose MO had resolved.
Conclusion
Interictal burden improved between 2 and 3 years after MOH diagnosis, yet clinically relevant burden persisted in more than one-quarter of patients whose MO had resolved. These findings suggest that recovery from MO and recovery from interictal burden do not necessarily proceed in parallel, supporting the inclusion of interictal burden in long-term MOH assessment.

Review Article

Glymphatic System Dysfunction in Migraine: From Cortical Spreading Depression to Migraine Chronification: Jeongwook Park; Headache Pain Res. 2026;27(3):174-185. Published online October 30, 2026; DOI: https://doi.org/10.62087/hpr.2026.0033

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Abstract PDF: Migraine has traditionally been understood as a neurovascular and neuroinflammatory disorder, but the glymphatic system, a brain-wide waste-clearance network mediated by cerebrospinal fluid and interstitial fluid exchange, has been proposed as a contributor to migraine pathophysiology. This review synthesizes current evidence on the role of glymphatic system dysfunction in migraine onset and chronification, integrating findings from preclinical animal models and multimodal clinical neuroimaging studies. Converging data suggest that cortical spreading depression during migraine attacks induces astrocyte swelling and aquaporin-4 (AQP4) depolarization, leading to physical collapse of the perivascular space, disruption of convective bulk flow, and impaired glymphatic clearance. This clearance failure may prolong the accumulation of nociceptive molecules, including calcitonin gene-related peptide, potassium ions, and glutamate, within the brain parenchyma, thereby exacerbating trigeminovascular sensitization and potentially contributing to migraine chronification. Clinically, alterations in neuroimaging markers such as the diffusion tensor imaging analysis along the perivascular space index and enlarged perivascular spaces have been associated with progressive fluid stagnation and an increased brain age gap in patients with chronic migraine. Glymphatic clearance failure may therefore contribute to the cycle of neuroinflammation and pain that sustains migraine. Future therapeutic strategies may benefit from moving beyond single-receptor blockade toward approaches that normalize the brain microenvironment, potentially by supporting glymphatic clearance through targeted pharmacological interventions and AQP4 channel modulation.

Original Article

Association between Psoriasis and Migraine in a Nationwide Cross-Sectional Study in Korea: Woo-Seok Ha, Soohyun Cho; Headache Pain Res. 2026;27(3):204-210. Published online October 30, 2026; DOI: https://doi.org/10.62087/hpr.2026.0031

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Abstract PDF: Purpose: Psoriasis and migraine are common chronic disorders that may share neuroimmune mechanisms, although the biological basis of their association remains uncertain. This study investigated the association between psoriasis and migraine, focusing on psoriasis severity and migraine subtypes, using a large population-based database.
Methods
This population-based cross-sectional study used data from the Korean National Health Insurance Service database. We identified 329,363 adults who underwent national health screening in 2019, including 8,892 patients with psoriasis and 320,471 individuals without psoriasis. Psoriasis severity was classified according to the use of systemic or biologic agents, and migraine was categorized according to the presence of aura. Multiple logistic regression analyses were performed with adjustment for age, sex, comorbidities, body mass index, smoking status, alcohol consumption, income, and residential area.
Results
In the fully adjusted model, patients with psoriasis had higher odds of prevalent migraine than individuals without psoriasis (odds ratio [OR], 1.172; 95% confidence interval [CI], 1.102–1.246). This association was observed in both mild psoriasis (OR, 1.167) and moderate-to-severe psoriasis (OR, 1.190). Psoriasis was also significantly associated with non-aura-coded migraine (OR, 1.171; 95% CI, 1.100–1.246), whereas migraine with aura was not significantly associated with psoriasis.
Conclusion
Psoriasis was cross-sectionally associated with higher odds of prevalent migraine, including non-aura-coded migraine, after adjustment for measured demographic, clinical, and lifestyle factors. Longitudinal studies are needed to determine temporality and address potential detection bias related to healthcare utilization.

Review Article

Is There a Role for Muscle Relaxants in Migraine Management? A Narrative Review: Heba Banihani, Marta Waliszewska-Prosół, Christopher Robinson, Abdulrazaq S. Albilali, Jeannine Abrons, Kinga Gecse, Merve Kozak, Mario M. F. Peres, Sait Ashina; Headache Pain Res. 2026;27(3):186-192. Published online October 30, 2026; DOI: https://doi.org/10.62087/hpr.2026.0025

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Abstract PDF: Migraine is a debilitating neurological condition that affects approximately 15% of the global population and frequently co-occurs with musculoskeletal conditions that add to its burden. Neck pain affects 73%–90% of patients and often prompts off-label prescribing of muscle relaxants to relieve perceived muscular contributions to headache. This narrative review examines the clinical evidence, pharmacological profiles, and safety considerations for centrally acting antispasmodic and antispasticity agents (tizanidine, baclofen, cyclobenzaprine, and methocarbamol), peripherally acting agents (dantrolene), and other agents (carisoprodol and eperisone). Although limited data from landmark trials in the early 2000s suggest potential preventive benefits of tizanidine and baclofen, high-quality, contemporary evidence supporting the routine use of muscle relaxants for migraine is lacking in the broader literature. Their substantial adverse effects, including sedation, dizziness, and the risk of dependence, may further increase patient disability. This review supports current clinical guidelines that prioritize migraine-specific therapies and suggests reserving muscle relaxants for individual cases with prominent musculoskeletal symptoms. Further studies are needed to assess the efficacy and safety of their short- and long-term use in migraine management.

Original Article

Preliminary Quantitative Electroencephalographic Evidence of Depression-Aligned Neurophysiological Patterns in Interictal Migraine: A Multi-Dataset Study: Dokyung Lee; Headache Pain Res. 2026;27(3):221-230. Published online October 30, 2026; DOI: https://doi.org/10.62087/hpr.2026.0022

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Abstract PDF: Purpose: This study aimed to examine whether interictal migraine shows neurophysiological patterns aligned with an external major depressive disorder (MDD) reference dataset, using quantitative electroencephalography (qEEG) indices less sensitive to absolute amplifier gain.
Methods
Three datasets were analyzed: ds005385 (normative reference, n=608; age-matched subset, 45–70 years, n=309), TDBRAIN (MDD, n=120; insomnia, n=30; healthy controls, n=47), and 25 patients with interictal migraine (chronic migraine, n=7; episodic migraine, n=18; mean age, 60.0 years; female, n=17). Eight candidate qEEG indices were ranked by effect size in TDBRAIN; the aperiodic exponent and frontal-parietal low-beta asymmetry (FP_asym_LowBeta) showed the largest effects and were selected for analysis. Four arousal-state windows were evaluated: eyes-closed resting, hyperventilation, post-hyperventilation 120 seconds, and post-hyperventilation 300 seconds.
Results
In TDBRAIN, patients with MDD showed a reduced aperiodic exponent (Cohen’s d=–0.63, p=0.001) and elevated FP_ asym_LowBeta (Cohen’s d=+0.83, p<0.001) versus healthy controls. In migraine, FP_asym_LowBeta was significantly elevated versus the age-matched normative reference after false discovery rate (FDR) correction during hyperventilation (p=0.015), post-hyperventilation 120 seconds (p=0.004), and post-hyperventilation 300 seconds (p=0.003); the eyes-closed resting window showed a nonsignificant trend (p=0.058). Compared with episodic migraine, chronic migraine showed a consistent but exploratory trend toward a lower aperiodic exponent across windows (Cohen’s d=-0.95 to -1.12, using sample-size-weighted pooled standard deviations), though no comparison survived FDR correction. A linear mixed-effects model showed no significant main effect of migraine subtype (p=0.084).
Conclusion
Interictal migraine showed preliminary qEEG patterns aligned with those observed in an external MDD reference dataset, particularly in frontal-parietal low-beta asymmetry during hyperventilation and recovery. However, these exploratory findings require validation in larger, age-matched cohorts with appropriate control for medication use and mood-related confounders.

Review Article

Pediatric Headache: Children and Adolescents

Gepants for the Treatment of Migraine in Children and Adolescents: Acute and Preventive Roles, Current Evidence, and Ongoing Trials: Ji-Hoon Na; Headache Pain Res. 2026;27(3):246-257. Published online October 19, 2026; DOI: https://doi.org/10.62087/hpr.2026.0034

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Abstract PDF: Migraine affects approximately 10% of children and adolescents and is often disabling, but evidence-based options for acute treatment and prevention remain limited. A high placebo response has also complicated pivotal pediatric trials. Therapies targeting the calcitonin gene-related peptide (CGRP) pathway have reshaped adult migraine care, and the approval of one CGRP monoclonal antibody for pediatric prevention has validated this target in pediatric patients. Gepants, small-molecule oral or intranasal CGRP receptor antagonists, are of particular interest because, unlike injectable antibodies, they offer acute or preventive treatment without vasoconstrictive activity. This review summarizes the pharmacology and adult evidence for the four approved gepants, their emerging pediatric use, and ongoing clinical trials. Depending on the agent, gepants have established efficacy for acute treatment or prevention in adults, with favorable long-term safety and no new hepatic or cardiovascular safety signals. Pediatric evidence is limited to small retrospective studies of off-label use in patients whose migraine is refractory to standard therapy. These reports suggest acceptable tolerability and possible benefit in some patients, but controlled trials are needed to determine efficacy. Phase 3 randomized trials are evaluating ubrogepant for acute treatment and atogepant and rimegepant for the prevention of episodic and chronic migraine in pediatric patients aged 6–17 years for acute treatment and episodic migraine prevention, and 12–17 years for chronic migraine prevention, with estimated completion expected between 2027 and 2032. Until controlled data become available, gepant use should be individualized and restricted to patients who have not responded to standard therapies. Pediatric dosing, long-term safety, and the lower age limit of benefit remain key questions.

Case Report

Pediatric Headache: Children and Adolescents

Early Infantile Onset of Presumed Recurrent Painful Ophthalmoplegic Neuropathy: Kristen M. Yang, Robert H. Fryer; Headache Pain Res. 2026;27(3):258-262. Published online October 19, 2026; DOI: https://doi.org/10.62087/hpr.2026.0032

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Abstract PDF: Recurrent painful ophthalmoplegic neuropathy (RPON) is a rare recurrent cranial neuropathy that usually presents in childhood, most often before 10 years of age. Although RPON primarily affects pediatric patients, onset before 1 year of age is exceedingly rare. We report the case of a 10-month-old boy who presented with recurrent episodes of disconjugate gaze and left-sided ptosis, leading to a presumptive diagnosis of RPON. Magnetic resonance imaging (MRI) showed enhancement of the left oculomotor nerve, a characteristic finding of RPON. To our knowledge, this is one of the youngest reported cases of presumed RPON with oculomotor nerve enhancement on MRI. This case highlights the importance of including RPON in the differential diagnosis of acute ophthalmoplegia in infants, outlines key diagnostic considerations, and compares the patient’s clinical and radiographic findings with those reported in previously published pediatric cases.

Editorial

Pediatric Migraine in Korea: New Opportunities in the Era of Mechanism-Based Prevention: Sanghyo Ryu; Headache Pain Res. 2026;27(3):171-173. Published online October 7, 2026; DOI: https://doi.org/10.62087/hpr.2026.0026

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PDF

Correction

Correction to “Alcohol-Induced Headache: A Narrative Review Based on Migraine Pathophysiology”: Woo-Seok Ha; Headache Pain Res. 2026;27(3):269-269. Published online August 19, 2026; DOI: https://doi.org/10.62087/hpr.2025.0027.e1; Corrects: Headache Pain Res 2026;27(1):21

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Letter to the Editor

Response to Comments on “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. 2026;27(3):266-268. Published online July 28, 2026; DOI: https://doi.org/10.62087/hpr.2026.0027

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Original Articles

Diagnostic Spectrum of Orthostatic Intolerance and Otologic Diseases in Pediatric Patients with Primary Headache and Dizziness: A Single-Center Retrospective Study: Hey-Joon Son, Kon-Hee Lee; Headache Pain Res. 2026;27(2):158-164. Published online June 30, 2026; DOI: https://doi.org/10.62087/hpr.2026.0021

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Abstract PDF: Purpose: Dizziness frequently coexists with headache in children and adolescents, but its diagnostic significance is often underrecognized. Orthostatic intolerance (OI) and otologic diseases are major causes of pediatric dizziness, yet distinguishing among these conditions remains clinically challenging. This study examined the diagnostic distribution of OI and otologic diseases in pediatric patients with primary headache-associated dizziness.
Methods
We retrospectively reviewed 310 patients aged 7–18 years who presented with both headache and dizziness; patients with secondary headache disorders were excluded. OI was assessed using head-up tilt testing and was classified primarily as orthostatic hypotension (OH) or postural orthostatic tachycardia syndrome (POTS). Otologic diseases, mainly peripheral vestibular disorders, were identified by otolaryngologists. Statistical analyses included the chi-squared test and one-way analysis of variance.
Results
The most common headache subtypes were migraine without aura (42.9%), vestibular migraine (15.8%), and tension- type headache (15.2%). OI was identified in 63.9% of patients, including OH in 40.6% and POTS in 23.2%; otologic diseases were present in 20.0%. The distributions of OI and otologic diseases did not differ significantly by headache subtype. OI was significantly associated with age and sex, with the POTS group having the highest mean age and a marked female predominance. Age also differed significantly across otologic disease subtypes.
Conclusion
In pediatric patients with headache and dizziness, OI and otologic diseases were common but were not associated with headache subtype. Instead, diagnostic patterns were more closely related to age and sex, suggesting that developmental and demographic factors should be considered when evaluating headache-associated dizziness in this population.

Pediatric Headache: Children and Adolescents

Serum Triglyceride Levels in Pediatric Migraine and Tension-Type Headache: A Retrospective Study: Ki Taek Oh; Headache Pain Res. 2026;27(2):154-157. Published online June 30, 2026; DOI: https://doi.org/10.62087/hpr.2026.0016

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Abstract PDF Supplementary Material: Purpose: Migraine and tension-type headache (TTH) are the most common primary headache disorders in children. However, potential metabolic differences between these conditions remain incompletely understood.
Methods
This retrospective study included pediatric patients diagnosed with migraine or TTH. Clinical characteristics and laboratory parameters were compared between the groups. Serum triglyceride (TG) levels were analyzed using multivariable linear regression adjusted for age and sex. Additional analyses included body mass index (BMI)-adjusted models and logarithmically transformed TG analyses.
Results
In total, 139 patients were included: 85 with migraine and 54 with TTH. Serum TG data were available for 101 patients. Mean TG levels were significantly higher in patients with TTH than in those with migraine (130.7±80.4 mg/dL vs. 92.1±42.4 mg/dL, p=0.006). This association remained significant after adjustment for age and sex (β=36.61 mg/dL, p=0.004), after logarithmic transformation (p=0.006), and in the BMI-adjusted subgroup analysis (β=42.84 mg/dL, p=0.040).
Conclusion
This exploratory retrospective study identified higher serum TG levels in pediatric patients with TTH than in those with migraine. Given the retrospective design and potential for residual confounding, these findings should be considered hypothesis- generating and require confirmation in prospective studies.

Guideline for the Treatment of Cluster Headache: A Clinical Practice Guideline from the Korean Headache Society: Byung-Su Kim, Pil-Wook Chung, Hong-Kyun Park, Mi Ji Lee, Jae Myun Chung, Kyung Min Kim, Jiyoung Kim, Heui-Soo Moon, Dae-Woong Bae, Jong-Hee Sohn, Tae-Jin Song, Wonwoo Lee, Soohyun Cho, Myoung-Jin Cha, Yun-Ju Choi, Miyoung Choi; Headache Pain Res. 2026;27(2):124-144. Published online June 30, 2026; DOI: https://doi.org/10.62087/hpr.2026.0011

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Abstract PDF Supplementary Material: Purpose: This clinical practice guideline (CPG) was developed by the Korean Headache Society (KHS) to provide evidence- based recommendations for the acute and preventive treatment of cluster headache (CH).
Methods
The CPG Committee of the KHS identified key clinical questions regarding the acute and preventive treatment of CH through a systematic literature review. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the quality of evidence and determine the strength of the evidence-based recommendations.
Results
For acute treatment, subcutaneous sumatriptan, intranasal zolmitriptan, intranasal sumatriptan, oral zolmitriptan, and oxygen are strongly recommended based on moderate-quality evidence. For preventive treatment, suboccipital steroid injection, oral corticosteroids, and galcanezumab (specifically for episodic CH) are strongly recommended based on moderate- quality evidence. Despite the low quality of evidence, verapamil is also strongly recommended, whereas lithium is recommended with a weaker strength of recommendation. Other oral triptans, NSAIDs, ergot derivatives, subcutaneous octreotide, intranasal lidocaine, and non-invasive vagus nerve stimulation (nVNS; specifically for episodic CH) are recommended for acute treatment based on expert consensus. For preventive treatment, topiramate, valproic acid, melatonin, and nVNS (as adjunctive therapy specifically for chronic CH) are recommended, whereas sphenopalatine ganglion stimulation, occipital nerve stimulation, and deep brain stimulation are recommended for patients with refractory chronic CH based on expert consensus.
Conclusion
This CPG provides evidence-based recommendations for the treatment of CH. In addition, the authors recommend the use of expert consensus-based treatments to bridge the gap between the available evidence and real-world clinical practice.

Review Article

Migraine Management in Pilots: A Focused Narrative Review for the Treating Neurologist: Chan-Young Park, Dongwook Kang, Heejung Lim, Hae-Bong Jeong, Kwang-Yeol Park; Headache Pain Res. 2026;27(2):108-116. Published online June 24, 2026; DOI: https://doi.org/10.62087/hpr.2026.0019

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Abstract PDF: Migraine, one of the leading global causes of disability, presents a complex challenge in aviation medicine. Headache is the fourth most common cause of in-flight pilot incapacitation, and cockpit-related exposures—including hypobaric hypoxia, low humidity, circadian disruption, and, in military aviation, sustained +Gz loading—may lower the migraine threshold. At the same time, aeromedical regulations restrict the medication options available to treating neurologists. This focused narrative review synthesizes pilot-specific clinical evidence and the principal regulatory documents issued by the International Civil Aviation Organization (ICAO Annex 1 and Doc 8984) and the U.S. Federal Aviation Administration (FAA Aviation Medical Examiner Guide) to provide neurologists with a practical framework for managing pilots with migraine. Simple analgesics, including acetaminophen/paracetamol, ibuprofen, naproxen, and aspirin at standard doses, are permitted under both ICAO and FAA frameworks. Triptans are permitted by the FAA after a 24- to 48-hour ground-observation period, whereas gepants such as ubrogepant and rimegepant require a 48-hour observation period. Beta-adrenergic blockers and calcium channel blockers are accepted preventive agents under both frameworks after a 7-day ground trial, whereas tricyclic antidepressants, topiramate, valproate, opioids, and butalbital-containing compounds are unacceptable. Anti–calcitonin gene-related peptide monoclonal antibodies are now accepted by the FAA after a 7-day ground trial, providing an additional certification-compatible option for pilots with migraine refractory to traditional preventive therapy. Most pilots with migraine can be managed in a manner compatible with continued flight duty when the neurologist selects medications within the applicable aeromedical formulary and documents clinical stability objectively to support certification.

Editorial

Looking into the Night: The Clinical Significance of Morning Headache: Soo-Kyoung Kim; Headache Pain Res. 2026;27(2):73-75. Published online June 18, 2026; DOI: https://doi.org/10.62087/hpr.2026.0024

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Letters to the Editor

Comment on “Subjective Cognitive Decline Patterns in Patients with Migraine, with or without Depression, versus Non-depressed Older Adults”: Jong-Hee Sohn; Headache Pain Res. 2026;27(3):263-265. Published online June 18, 2026; DOI: https://doi.org/10.62087/hpr.2026.0023

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Sleep Bruxism as a Contributing Factor to Morning Headache: A Response to Recent Commentary: Yooha Hong, Hee-Jin Im; Headache Pain Res. 2026;27(2):167-168. Published online June 18, 2026; DOI: https://doi.org/10.62087/hpr.2026.0020

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Review Articles

Temporal Evolution and Multimodal Neuroimaging in Reversible Cerebral Vasoconstriction Syndrome, Arterial Dissection, and Cerebral Venous Thrombosis: Young-Eun Gil; Headache Pain Res. 2026;27(2):76-95. Published online June 18, 2026; DOI: https://doi.org/10.62087/hpr.2026.0018

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Abstract PDF: Cerebrovascular disorders are important secondary causes of headache, but diagnosis can be challenging because headache may be the earliest or only presenting symptom and initial neuroimaging findings are often normal or nonspecific. This review provides a systematic, imaging-focused discussion of three representative cerebrovascular headache disorders: reversible cerebral vasoconstriction syndrome (RCVS), cervical and intracranial artery dissection, and cerebral venous thrombosis (CVT). For each condition, we describe characteristic findings across relevant imaging modalities, including computed tomography, computed tomography angiography, magnetic resonance imaging (MRI), magnetic resonance angiography, vessel wall (VW)-MRI, and susceptibility-sensitive sequences. We also discuss the temporal evolution of imaging findings, which underlies several common diagnostic pitfalls. In RCVS, angiographic vasoconstriction propagates centripetally from distal to proximal vessels, and contrast-enhanced fluid-attenuated inversion recovery imaging can detect blood–brain barrier disruption before vasoconstriction becomes angiographically apparent. In arterial dissection, VW-MRI can show mural features that confirm the diagnosis and may help stratify ischemic risk. In CVT, susceptibility-weighted imaging improves detection of cortical vein thrombosis, a subtype that can be missed on conventional venography. Across all three conditions, single-time-point imaging may be misleading, and serial imaging is often needed to increase diagnostic certainty because interval changes may reveal findings not present on the initial study. By integrating modality-specific findings with their temporal dynamics, this review proposes a practical imaging framework for the early and accurate diagnosis of cerebrovascular secondary headache disorders.

Finding the Sweet Spot between Medication Overuse and Underuse in Headache Medicine: Hong-Kyun Park; Headache Pain Res. 2026;27(2):96-107. Published online June 15, 2026; DOI: https://doi.org/10.62087/hpr.2026.0012

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Abstract PDF: Medication-overuse headache (MOH) is a well-recognized secondary headache caused by the frequent use of acute symptomatic medications, particularly among patients with underlying primary headache disorders such as migraine. Medication-underuse headache (MUH) is a recently proposed conceptual framework describing the suboptimal use of indicated treatments, including underuse, delayed administration, poor adherence, or premature discontinuation, all of which may contribute to headache progression or chronification. Both conditions share pathophysiological substrates, including central sensitization, impaired descending pain modulation, and dysfunctional reward processing, which are rooted in dopaminergic mesocorticolimbic dysregulation and trigeminovascular sensitization. MUH may arise from fear of side effects, fear of withdrawal, poor adherence, or inadequate access to care and may lead to an escalating headache burden and increased reliance on acute treatments, potentially predisposing patients to MOH. Conversely, managing MOH without addressing underuse-related barriers may contribute to treatment resistance or relapse. Recent evidence suggests that calcitonin gene-related peptide (CGRP)-targeted monoclonal antibodies can achieve clinically meaningful improvement in MOH even without mandatory medication withdrawal, challenging the traditional assumption that detoxification is required for treatment response. MOH is also increasingly viewed as a multidimensional neurological and biobehavioral disorder, with preliminary neuroimaging data indicating that mindfulness-based interventions can modulate pain- and reward-related brain networks. This narrative review summarizes the clinical features and mechanisms of MOH and MUH and proposes a comprehensive management framework integrating patient education, structured lifestyle and mindfulness-based interventions, early initiation of preventive therapy, and CGRP-targeted treatments, with the aim of achieving therapeutic balance—not too much, not too little—and improving long-term outcomes.

Letter to the Editor

Comments on “Brain Glymphatic and Lymphatic Systems in Migraine: Mechanistic Insights and Neuromodulation Perspectives with an Emphasis on Ultrasound-Based Approaches”: Soo-Jin Cho; Headache Pain Res. 2026;27(2):169-170. Published online June 9, 2026; DOI: https://doi.org/10.62087/hpr.2026.0015

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Original Article

The Impact of Limited Insurance Coverage on Long-Term Persistence with Anti-CGRP Monoclonal Antibody Therapy: A Multicenter Real-World Study in Korea: Mi-Kyoung Kang, Jong-Hee Sohn, Myoung-Jin Cha, Yoo Hwan Kim, Yooha Hong, Hee-Jin Im, Soo-Jin Cho; Headache Pain Res. 2026;27(2):145-153. Published online June 4, 2026; DOI: https://doi.org/10.62087/hpr.2026.0007

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Abstract PDF: Purpose: Anti-calcitonin gene-related peptide monoclonal antibodies (anti-CGRP mAbs) are effective preventive therapies for migraine. However, their high cost limits long-term use. In Korea, coverage of anti-CGRP mAbs by the National Health Insurance Service (NHIS) is highly restricted. This study aimed to evaluate the association between NHIS coverage and treatment persistence in a real-world setting.
Methods
This retrospective multicenter study included adult patients with migraine (≥18 years) who received anti-CGRP mAb therapy at four tertiary hospitals in Korea. Treatment compliance was assessed using persistence, defined as continuous treatment duration; persistence rates; and adherence, defined as the proportion of days covered. Reasons for treatment discontinuation were also analyzed. Treatment compliance was compared according to NHIS coverage, and treatment effectiveness was compared according to NHIS coverage and treatment continuation.
Results
Among 140 patients treated with anti-CGRP mAbs, only 12 (8.6%) received NHIS-covered therapy. Compared with the non-covered group, the NHIS-covered group had a lower discontinuation rate (50.0% [6/12] vs. 73.4% [94/128]; p=0.101) and higher persistence rates at 6 months (80.0% vs. 66.0%; p=0.493) and 12 months (66.7% vs. 47.2%; p=0.312). However, these differences were not statistically significant. Treatment effectiveness, assessed by changes in monthly headache days, did not differ significantly according to NHIS coverage or treatment continuation.
Conclusion
Treatment persistence appears to be influenced by multiple factors in real-world practice. NHIS coverage may support treatment continuation by improving access and reducing the financial burden. These findings highlight the importance of healthcare-system factors in optimizing long-term preventive treatment strategies for migraine.

Review Article

Trigeminal Neuralgia: Pathophysiology, Clinical Features, and Therapeutic Management: Ekene Nnagha, Chidubem Adi, Daniel Akpan; Headache Pain Res. 2026;27(2):117-123. Published online June 4, 2026; DOI: https://doi.org/10.62087/hpr.2026.0005

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Abstract PDF: Trigeminal neuralgia (TN) is a severe, disabling neuropathic facial pain disorder classified among cranial neuralgias within headache medicine. Despite well-established diagnostic criteria, TN remains frequently misdiagnosed, particularly in dental and primary care settings. This review provides a clinically focused overview of the epidemiology, pathophysiology, classification, diagnostic approach, and contemporary management of TN, with relevance to headache and pain research and clinical practice. Neurovascular compression with focal demyelination at the trigeminal nerve root entry zone is considered the predominant mechanism in classical TN. Diagnosis is primarily clinical and guided by International Classification of Headache Disorders, 3rd edition criteria, with magnetic resonance imaging essential for excluding secondary and idiopathic causes. Carbamazepine and oxcarbazepine remain first-line therapies, whereas microvascular decompression and minimally invasive neurosurgical procedures provide effective options for medically refractory disease. TN requires accurate diagnosis and individualized management. Advances in pharmacological and interventional treatments have improved outcomes and underscore the importance of multidisciplinary care within headache and pain medicine.

Letter to the Editor

Comments on “Morning Headaches: An In-Depth Review of Causes, Associated Disorders, and Management Strategies”: Seong Taek Kim; Headache Pain Res. 2026;27(2):165-166. Published online May 29, 2026; DOI: https://doi.org/10.62087/hpr.2026.0014

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Citations

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Sleep Bruxism as a Contributing Factor to Morning Headache: A Response to Recent Commentary
Yooha Hong, Hee-Jin Im
Headache and Pain Research.2026; 27(2): 167. CrossRef

Original Article

Natural Diagnostic Classes of Headache Disorders: Latent Class Analysis of a Population-Based Study: Wonwoo Lee, Seok-Jae Heo, Jungyon Yum, Min Kyung Chu; Headache Pain Res. 2026;27(1):30-42. Published online February 26, 2026; DOI: https://doi.org/10.62087/hpr.2026.0004

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Abstract PDF Supplementary Material: Purpose: The International Classification of Headache Disorders, 3rd edition (ICHD-3), defines headache diagnoses based on combinations of clinical symptoms. Diagnostic overlap is common, and symptom variability complicates diagnostic classification. We evaluated natural classes of headache disorders using a statistical approach and compared these classes with ICHD-3 diagnostic categories.
Methods
Data from a nationwide, population-based web survey on headache and sleep conducted in South Korea (n=3,030) were analyzed. Participants who reported headache within the past year (n=1,938) were included. Latent class analysis was performed using categorical ICHD-3 diagnostic criteria to identify distinct classes. The characteristics of each class and the distribution of ICHD-3 primary headache diagnoses were examined.
Results
Nine classes were identified, comprising 626, 54, 248, 148, 187, 143, 79, 61, and 392 individuals. Three classes were tension-type headache (TTH)–like: Class 1 was male-dominant mild bilateral TTH, Class 8 represented classic, severe TTH, and Class 9 was mild unilateral TTH. Class 4 showed a typical migraine phenotype and contained most migraine cases. Classes 5 and 6 were dominated by probable migraine (PM) and differed mainly in sensory sensitivity and disability, which were higher in Class 6. Classes 2, 3, and 7 were categorized as “other headache.” Class 2 had the highest prevalence of medication-overuse headache (MOH), whereas Class 3 was characterized by mild headache with nausea. Class 7 showed a mixed-type profile with prominent photophobia. Severity and central sensitization markers were key classifiers.
Conclusion
Latent class analysis identified nine clinically distinct headache classes. PM was clearly distinct from both TTH and migraine. One subtype within the “other headache” class showed the highest MOH burden.

Letter to the Editor

The honored list of reviewer in 2025: Headache Pain Res. 2026;27(1):71-71. Published online February 26, 2026; DOI: https://doi.org/10.62087/hpr.2026.0001

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Original Article

Cerebrovascular Hemodynamic Responses to Breath-Holding in Migraine: A Longitudinal Functional Near-Infrared Spectroscopy Study Comparing a Calcitonin Gene-Related Peptide Monoclonal Antibody and Oral Preventive Treatment: Dong A. Yea, Jong Kwan Choi, Yoo Hwan Kim; Headache Pain Res. 2026;27(1):52-63. Published online February 24, 2026; DOI: https://doi.org/10.62087/hpr.2025.0029

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Abstract PDF Supplementary Material

Purpose: Altered cerebrovascular reactivity has been reported in migraine; however, longitudinal changes during preventive treatment remain unclear. This observational study aimed to describe and compare longitudinal cerebrovascular responses derived from functional near-infrared spectroscopy (fNIRS) during a breath-holding test between patients treated with a calcitonin gene-related peptide (CGRP) monoclonal antibody and those receiving oral preventive medications.
Methods
Twenty-four patients with migraine were enrolled (CGRP group, n=12; oral group, n=12). fNIRS over the prefrontal cortex was performed at baseline and after 3 months during a standardized breath-holding protocol. Oxygenated (HbO), deoxygenated, and total hemoglobin signals were used to derive breath-holding and recovery indices. Clinical outcomes included monthly headache days, acute medication days, disability, mood scales, and Patient Global Impression of Change.
Results
Monthly headache days decreased in both groups (CGRP: Δ=–2.00, p=0.26; oral: Δ=–1.50, p=0.48), with no between- group difference (p=0.85). Acute medication days were significantly reduced only in the CGRP group (Δ=–7.00, p=0.03). Migraine Disability Assessment (MIDAS) scores improved significantly in the CGRP group (Δ=–21.25, p=0.02), with no significant between-group differences. During breath-holding, HbO increased across channels in both groups and was followed by a gradual decline during the recovery phase. Longitudinal analyses demonstrated group-dependent differences in temporal change patterns, with a treatment×time interaction reaching significance at the uncorrected level in a representative channel (Channel 6: F(1,16)=8.448, p=0.010), but not after multiple-comparison correction (p=0.155).
Conclusion
fNIRS with a breath-holding challenge enables longitudinal assessment of cerebrovascular responses during migraine preventive treatment. The observed differences should be interpreted descriptively in terms of temporal change patterns. Larger studies are needed to clarify clinical significance.

Citations

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Machine Learning Classification of Migraine Using fNIRS During a Postural Task
Emre Yorgancigil, Gülnaz Yükselen, Roksi Franci, Erkan Acar, Elif Ilgaz Aydinlar, Pinar Yalinay Dikmen, Ugur Uygunoglu, Aksel Siva, Abdullah Arcan, Feride Irem Simsek, Sinem Burcu Erdogan, Ata Akin
Brain Sciences.2026; 16(9): 927. CrossRef

Review Articles

Headache and Stroke: A Review: Jong S. Kim; Headache Pain Res. 2026;27(1):7-12. Published online February 24, 2026; DOI: https://doi.org/10.62087/hpr.2025.0028

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Abstract PDF

Headache is a common disorder that is usually unaccompanied by focal neurological dysfunction. Less commonly, headache may be associated with central nervous system diseases such as stroke. Headache can occur at the time of stroke onset, but it may also precede or follow the onset of stroke. Nevertheless, headaches associated with stroke have not been sufficiently studied, in part because stroke physicians are primarily focused on diagnosis, risk factors, pathophysiological mechanisms, imaging findings, and treatment (e.g., thrombolysis and endovascular therapy) rather than on headache. In this narrative review, I describe the frequency and characteristics of headache across various stroke subtypes, including ischemic stroke, transient ischemic attack, intracerebral hemorrhage, subarachnoid hemorrhage, and other miscellaneous conditions such as venous infarction, arterial dissection, and reversible cerebral vasoconstriction syndrome.

Citations

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Primary or Secondary Headache Disorders in Moyamoya Disease and Cerebral Infarction: Clinical Challenges and the Potential Role of Non-Vasoconstrictive Migraine Therapies
Soo-Jin Cho
Headache and Pain Research.2026; 27(1): 1. CrossRef
Temporal Evolution and Multimodal Neuroimaging in Reversible Cerebral Vasoconstriction Syndrome, Arterial Dissection, and Cerebral Venous Thrombosis
Young-Eun Gil
Headache and Pain Research.2026; 27(2): 76. CrossRef

Alcohol-Induced Headache: A Narrative Review Based on Migraine Pathophysiology: Woo-Seok Ha; Headache Pain Res. 2026;27(1):21-29. Published online February 23, 2026; DOI: https://doi.org/10.62087/hpr.2025.0027; Correction in: Headache Pain Res 2026;27(3):269

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Abstract PDF: Alcohol-induced headache (AIH) is one of the most common headache experiences and is associated with a substantial socioeconomic burden; however, its pathophysiological mechanisms and clinical classification remain inadequately defined. Accumulating evidence indicates that AIH shares key biological pathways with migraine, particularly involving activation of the trigeminovascular system and calcitonin gene-related peptide (CGRP) signaling. Although currently available hangover remedies are supported by limited high-quality evidence, anti-CGRP treatments have emerged as a biologically plausible option for the situational prevention and acute treatment of AIH. A phenotype-based approach is therefore essential for achieving accurate diagnosis and effective management of alcohol-related headaches. Future well-designed clinical trials focusing on CGRP antagonists are warranted to address this common yet neglected disorder.

Brain Glymphatic and Lymphatic Systems in Migraine: Mechanistic Insights and Neuromodulation Perspectives with an Emphasis on Ultrasound-Based Approaches: Jaeho Kim; Headache Pain Res. 2026;27(1):13-20. Published online February 19, 2026; DOI: https://doi.org/10.62087/hpr.2026.0003

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Abstract PDF

Migraine is a prevalent and disabling neurological disorder in which established pathophysiological mechanisms, including trigeminovascular activation and calcitonin gene-related peptide (CGRP) signaling, do not fully account for interindividual susceptibility, chronification, or treatment refractoriness. Advances in neurobiology have drawn attention to brain clearance pathways, specifically the glymphatic system and meningeal lymphatic vessels, as potential modulators of neuroinflammation and cerebrospinal fluid (CSF) dynamics. These systems regulate the exchange and drainage of CSF, interstitial solutes, and immune mediators and are strongly influenced by sleep and state-dependent physiology, both of which are closely linked to migraine pathophysiology. In this narrative review, we describe the anatomical and functional organization of brain lymphatic and glymphatic systems and critically evaluate emerging evidence connecting these pathways to migraine. Indirect human imaging studies and experimental models indicate that alterations in perivascular transport, meningeal lymphatic drainage, sleep disruption, and CGRP-related signaling may converge to modulate brain clearance efficiency in migraine. Although the available evidence remains heterogeneous and largely indirect, these findings offer a coherent framework for integrating clearance-related physiology into existing migraine models. We further discuss neuromodulation as a potential strategy for influencing brain clearance mechanisms. In particular, transcranial low-intensity ultrasound has been shown to enhance CSF movement in vivo, providing direct mechanistic support for clearance modulation. Other neuromodulation modalities may exert indirect effects through autonomic regulation, neural oscillations, or vascular dynamics. While clinical evidence remains preliminary, a clearance-oriented perspective may help guide future biomarker development and translational research in migraine.

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Comments on “Brain Glymphatic and Lymphatic Systems in Migraine: Mechanistic Insights and Neuromodulation Perspectives with an Emphasis on Ultrasound-Based Approaches”
Soo-Jin Cho
Headache and Pain Research.2026; 27(2): 169. CrossRef

Editorials

Pediatric Headache in Korea: Beyond a Common Complaint to a Chronic Neurological Condition: Yun Jin Lee; Headache Pain Res. 2026;27(1):4-6. Published online February 13, 2026; DOI: https://doi.org/10.62087/hpr.2026.0006

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2 Citations

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Citations

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Serum Triglyceride Levels in Pediatric Migraine and Tension-Type Headache: A Retrospective Study
Ki Taek Oh
Headache and Pain Research.2026; 27(2): 154. CrossRef
Pediatric Migraine in Korea: New Opportunities in the Era of Mechanism-Based Prevention
Sanghyo Ryu
Headache and Pain Research.2026; 27(3): 171. CrossRef

Primary or Secondary Headache Disorders in Moyamoya Disease and Cerebral Infarction: Clinical Challenges and the Potential Role of Non-Vasoconstrictive Migraine Therapies: Soo-Jin Cho; Headache Pain Res. 2026;27(1):1-3. Published online February 13, 2026; DOI: https://doi.org/10.62087/hpr.2026.0002

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Original Articles

Pediatric Headache: Children and Adolescents

Adult-Onset versus Pediatric-Onset Episodic Cluster Headaches: Results from the Korean Cluster Headache Registry: Pil-Wook Chung, Byung-Su Kim, Jeong-Wook Park, Jong-Hee Sohn, Mi Ji Lee, Byung-Kun Kim, Min Kyung Chu, Tae-Jin Song, Soo-Kyoung Kim, Heui-Soo Moon, Kyungmi Oh, Soo-Jin Cho; Headache Pain Res. 2026;27(1):64-70. Published online February 13, 2026; DOI: https://doi.org/10.62087/hpr.2025.0021

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Abstract PDF: Purpose: This study aimed to compare clinical characteristics between pediatric-onset and adult-onset cluster headache (CH) using data from the Korean Cluster Headache Registry, a nationwide, prospective, multicenter registry.
Methods
This cross-sectional observational study analyzed data collected over a 4-year period from a prospective multicenter registry. A total of 337 patients aged ≥19 years with episodic CH were included. Participants were classified as having pediatric-onset CH (onset≤18 years) or adult-onset CH (onset>18 years). Demographic and clinical features, smoking status, and psychiatric comorbidities were compared between groups.
Results
Pediatric-onset CH was reported in 24.6% of patients (n=83). The diagnostic delay was significantly longer in the pediatric-onset group compared with the adult-onset group (10.1 years vs. 6.2 years, p<0.001). Patients with pediatric-onset CH experienced more severe headache attacks (numerical rating scale 9.2 vs. 8.9, p=0.025), although attack duration, frequency, and other clinical features were similar between groups. Smoking exposure was lower in the pediatric-onset group, suggesting potential differences in environmental risk factors. No significant differences were observed in psychiatric comorbidity or headache-related disability.
Conclusion
Pediatric-onset CH is relatively common and shares most clinical features with adult-onset CH, apart from greater attack severity and lower smoking exposure. The longer diagnostic delay in pediatric-onset cases highlights the need for improved awareness and earlier recognition. Further research is warranted to elucidate the underlying pathophysiological mechanisms and long-term outcomes in pediatric-onset CH.

The Impact of Anti-Calcitonin Gene-Related Peptide Monoclonal Antibodies on Sleep Quality and Daytime Sleepiness in Migraine Patients: A Multicenter Study: Rita Cagigal, Ângelo Fonseca, Bárbara Martins, Catarina Fernandes, Sandra Palma, Carolina Guerreiro, Carla Morgado, Diana Valente, Miguel Miranda, Joana Silva, Miguel Saianda-Duarte, Sofia Casanova, Mariana Branco, Ana Luísa Rocha, Henrique Delgado, Elsa Parreira, Filipe Palavra; Headache Pain Res. 2026;27(1):43-51. Published online January 28, 2026; DOI: https://doi.org/10.62087/hpr.2025.0022

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2 Citations

Abstract PDF

Purpose: This study aimed to determine whether patients with migraine experience improvements in self-reported sleep quality and daytime sleepiness after starting monoclonal antibody (mAb) therapy targeting the calcitonin gene-related peptide (CGRP) or its receptor, and to explore the association between treatment efficacy and improvements in sleep quality.
Methods
This prospective, multicenter, observational, longitudinal study was conducted across 12 headache centers. Adults with episodic or chronic migraine who began anti-CGRP mAb therapy were assessed at baseline, 3 months, and 6 months. Sleep quality and daytime sleepiness were evaluated using the Portuguese version of the Pittsburgh Sleep Quality Index (PSQI-PT) and the Portuguese version of the Epworth Sleepiness Scale (ESS-PT), respectively.
Results
Of 118 enrolled patients, 109 completed the study (86.4% female; mean age, 43.6 years). A significant improvement in sleep quality was observed, with median PSQI-PT scores decreasing from 9 at baseline to 6 at 6 months (p<0.001). Daytime sleepiness also improved, with median ESS-PT scores decreasing from 7 to 6 (p=0.04). Migraine frequency decreased significantly, from a median of 13 to 4 monthly migraine days (p<0.001). Greater migraine improvement was independently associated with greater PSQI-PT improvement (p<0.001), whereas changes in ESS-PT were not correlated with treatment efficacy.
Conclusion
Anti-CGRP mAb therapy was associated with significant improvements in sleep quality, likely mediated through migraine relief. Changes in ESS-PT were not correlated with treatment efficacy, suggesting a possible interaction between migraine mechanisms and CGRP-mediated sleep–wake regulation. Future research should focus on clarifying the mechanisms underlying these associations.

Citations

Citations to this article as recorded by

Looking into the Night: The Clinical Significance of Morning Headache
Soo-Kyoung Kim
Headache and Pain Research.2026; 27(2): 73. CrossRef
Beyond pain relief: rethinking sleep outcomes in CGRP-targeted migraine therapy
Marc Daou, Joyce K. Lee-Iannotti, Jennifer Robblee
Sleep Medicine Reviews.2026; 90: 102375. CrossRef

Review Article

The Hidden Risks of Medication Underuse in Migraine Progression: Heui-Soo Moon, Pil-Wook Chung; Headache Pain Res. 2025;26(3):209-217. Published online October 23, 2025; DOI: https://doi.org/10.62087/hpr.2025.0019

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112 Download
6 Citations

Abstract PDF

Migraine is a progressive neurological disorder in which inadequate treatment can lead to chronification. For decades, clinical attention has centered on medication overuse headache (MOH) as the primary iatrogenic risk factor for this progression. However, medication underuse (MU) has emerged as a critical yet less established framework for understanding gaps in migraine care. This review reframes MU, which includes ineffective therapies, delayed administration, and non-adherence due to intolerability, as an active contributor to disease progression. Untreated or undertreated migraine attacks promote the development of central sensitization, a state of neuronal hyperexcitability that increases attack frequency, severity, and treatment resistance. This paper posits that MU and MOH are not opposing concepts but interconnected manifestations of suboptimal disease management. Specifically, disease progression driven by MU can directly precipitate the escalating medication use that characterizes MOH, resulting in a more refractory clinical state. Therefore, preventing chronification requires a paradigm shift from merely avoiding overuse to achieving optimal use. This entails adherence to evidence-based guidelines for both acute and preventive therapy—implementing stratified acute care within the neurobiological window to prevent central sensitization and initiating timely preventive treatment in eligible patients to reduce the overall attack burden. The integration of novel targeted therapies provides new opportunities to overcome the limitations of traditional agents. Ultimately, reducing the risks associated with MU through proactive, evidence-based management and strong patient–clinician communication is essential to alter the natural history of migraine and prevent the long-term disability associated with its progression.

Citations

Citations to this article as recorded by

Pediatric Headache in Korea: Beyond a Common Complaint to a Chronic Neurological Condition
Yun Jin Lee
Headache and Pain Research.2026; 27(1): 4. CrossRef
Finding the Sweet Spot between Medication Overuse and Underuse in Headache Medicine
Hong-Kyun Park
Headache and Pain Research.2026; 27(2): 96. CrossRef
Real-world effectiveness and safety of CGRP monoclonal antibodies in elderly migraine patients: a Korean multicenter study
Soohyun Cho, Mi-Kyoung Kang, Heui-Soo Moon, Mi Ji Lee, Soo-Kyoung Kim, Hong-Kyun Park, Woo-Seok Ha, Min Kyung Chu, Young-Eun Gil, Byung-Su Kim, Soo-Jin Cho
The Journal of Headache and Pain.2026;[Epub] CrossRef
Association Between Instability in Triptan Use and Interictal Burden in Migraine: A Cross-Sectional Study
Masakazu Ishii, Ikumi Ito, Hirotaka Katoh
BPB Reports.2026; 9(4): 134. CrossRef
Migraine attack prediction using wearable biosensor data
Saulius Andruškevičius, Viroslava Kapustynska, Vytautas Abromavičius, Henrik Winther Schytz, Kristina Ryliškienė
Cephalalgia.2026;[Epub] CrossRef
Pediatric Migraine in Korea: New Opportunities in the Era of Mechanism-Based Prevention
Sanghyo Ryu
Headache and Pain Research.2026; 27(3): 171. CrossRef

Case Report

Isolated Dental and Lower-Facial Pain Mimicking Trigeminal Neuropathy: An Indirect Carotid-Cavernous Fistula: Byoungchul Choi, Chulho Kim, Sung-Hwan Kim, Jong-Hee Sohn; Headache Pain Res. 2025;26(3):226-231. Published online October 22, 2025; DOI: https://doi.org/10.62087/hpr.2025.0020

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Abstract PDF: Carotid-cavernous fistula (CCF) is a pathological arteriovenous communication in which carotid arterial flow is diverted into the cavernous sinus. Clinical manifestations typically include ocular signs, cranial neuropathies, and headache. Neurologic deficits most commonly reflect involvement of cranial nerves III, IV, V1/V2, and VI within or along the cavernous sinus; in contrast, isolated trigeminal presentations are rare, and V3 involvement is particularly uncommon. A 69-year-old woman presented with isolated V2/V3-territory pain, perceived as molar, gingival, and lower facial discomfort. Her symptoms were initially misattributed to trigeminal neuropathy or dental pathology. Subsequently, she developed horizontal diplopia, and bedside testing localized a right abducens palsy. Brain magnetic resonance imaging revealed findings suspicious for a CCF, which was angiographically confirmed as an indirect CCF. Following embolization, the patient’s pain markedly improved, implicating the CCF as the source of the V2/V3 symptoms. This case highlights that an atypical, trigeminal-predominant onset—even with pain limited to the V2/V3 distribution—may indicate an indirect CCF. When atypical trigeminal neuropathy is suspected and dental or other peripheral causes are excluded, clinicians should consider the possibility of a CCF.

Original Article

Trigeminal Autonomic Cephalalgias Following Unilateral Dorsolateral Medullary Infarction: A Case Series and Literature Review: Jae-Myung Kim, Hak-Loh Lee, You-Ri Kang, Joon-Tae Kim, Seung-Han Lee; Headache Pain Res. 2025;26(3):218-225. Published online October 22, 2025; DOI: https://doi.org/10.62087/hpr.2025.0013

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Abstract PDF

Purpose: Secondary trigeminal autonomic cephalalgias (TACs) are typically associated with posterior fossa abnormalities, such as tumors and vascular malformations. However, TACs following brainstem infarctions are rarely reported. This study aimed to characterize the clinical and anatomical features of TACs after unilateral dorsolateral medullary infarction.
Methods
We analyzed four patients with dorsolateral medullary infarction who developed secondary TACs, diagnosed using the International Classification of Headache Disorders, third edition criteria. All patients underwent detailed neurological examinations and neuroimaging, including diffusion-weighted magnetic resonance imaging and magnetic resonance angiography. Additionally, five published cases were identified through a literature review and analyzed in conjunction with our cohort.
Results
All patients exhibited stabbing or electric shock-like pain in the ipsilateral periorbital, hemifacial, and temporal regions. Headaches developed weeks to months post-stroke with brief attacks (1–2 minutes) occurring 1–5 times daily. Lacrimation and conjunctival injection were common. Three patients were diagnosed with short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), while a fourth had short-lasting unilateral neuralgiform with cranial autonomic symptoms (SUNA). Each patient, as well as four of the five from the literature, exhibited ipsilateral facial sensory loss, suggesting involvement of the trigeminal spinal tract and nucleus. Delayed headache onset was more frequent in persistent cases.
Conclusion
Headache characteristics were more consistent with SUNCT/SUNA than with typical cluster headaches. Careful neurological examination is essential to detect focal signs and guide neuroimaging for identifying secondary causes. Clinicians should consider secondary TACs in patients with new-onset SUNCT/SUNA and focal brainstem signs.

Citations

Citations to this article as recorded by

Primary or Secondary Headache Disorders in Moyamoya Disease and Cerebral Infarction: Clinical Challenges and the Potential Role of Non-Vasoconstrictive Migraine Therapies
Soo-Jin Cho
Headache and Pain Research.2026; 27(1): 1. CrossRef

Review Articles

Interictal Burden of Migraine: A Narrative Review: Soo-Kyoung Kim, Todd J. Schwedt; Headache Pain Res. 2025;26(3):200-208. Published online October 21, 2025; DOI: https://doi.org/10.62087/hpr.2025.0018

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3 Citations

Abstract PDF

Migraine is a chronic neurological disorder associated with substantial disability and societal costs. Traditionally, research and clinical care have focused on the ictal phase, characterized by headache and accompanying symptoms. However, growing evidence suggests that a considerable portion of migraine-related disability occurs between attacks, known as the interictal burden (IIB). IIB encompasses a wide spectrum of cognitive, emotional, sensory, and functional impairments that persist during headache-free periods, including fatigue, allodynia, photophobia, cognitive dysfunction, anticipatory anxiety, and social withdrawal. These symptoms can markedly reduce quality of life, work productivity, and family functioning, even in individuals with infrequent attacks. In a descriptive survey of 506 migraine respondents, 67% experienced severe IIB. The effects of IIB extend beyond patients themselves, contributing to presenteeism in the workplace and imposing emotional and logistical strain within families. Several instruments, including the Migraine Interictal Burden Scale (MIBS-4), Migraine-Specific Quality of Life Questionnaire (MSQ v2.1), Headache Impact Test (HIT-6), and Migraine Disability Assessment (MIDAS), have been employed to assess different dimensions of IIB. Nonetheless, no single comprehensive and standardized tool fully captures the multidimensional nature of IIB. Recognizing and addressing IIB is essential for delivering holistic, patient-centered migraine care. Future research should focus on developing validated assessment instruments and incorporating IIB measures into clinical trials and routine practice to better understand and alleviate the hidden burden of migraine.

Citations

Citations to this article as recorded by

Brain Glymphatic and Lymphatic Systems in Migraine: Mechanistic Insights and Neuromodulation Perspectives with an Emphasis on Ultrasound-Based Approaches
Jaeho Kim
Headache and Pain Research.2026; 27(1): 13. CrossRef
Pediatric Headache in Korea: Beyond a Common Complaint to a Chronic Neurological Condition
Yun Jin Lee
Headache and Pain Research.2026; 27(1): 4. CrossRef
Pediatric Migraine in Korea: New Opportunities in the Era of Mechanism-Based Prevention
Sanghyo Ryu
Headache and Pain Research.2026; 27(3): 171. CrossRef

Gepants for Migraine: An Update on Long-Term Outcomes and Safety Profiles: Soohyun Cho, Kimoon Chang; Headache Pain Res. 2025;26(3):184-192. Published online October 21, 2025; DOI: https://doi.org/10.62087/hpr.2025.0012

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Abstract PDF

Calcitonin gene-related peptide receptor antagonists, also referred to as gepants, represent a transformative advancement in migraine pharmacotherapy, providing both acute and preventive treatment options without the vasoconstrictive limitations of triptans. Since their initial approval in 2019, gepants have gained widespread clinical adoption, necessitating comprehensive evaluation of their long-term safety and efficacy. This review synthesizes current evidence on four calcitonin gene-related peptide receptor antagonists (rimegepant, atogepant, ubrogepant, and zavegepant) derived from pivotal trials, open-label extension studies, and real-world observational data. Rimegepant demonstrates sustained efficacy and minimal adverse events over 52 weeks, with no evidence of medication-overuse headaches or hepatotoxicity. Atogepant maintains progressive clinical benefits and favorable tolerability for up to 1 year, exhibiting low rates of treatment-emergent adverse events and discontinuation. Ubrogepant remains effective and well-tolerated during long-term intermittent use, with no clinically significant safety signals over extended exposure. Zavegepant, the first intranasal gepant, shows promising long-term tolerability, with the most frequently reported localized adverse event being transient dysgeusia. No consistent hepatic, cardiovascular, or serious systemic toxicity has emerged for any of the agents, and discontinuation rates due to adverse events remain consistently low. Current evidence supports gepants as safe and effective therapies for long-term migraine management, although ongoing surveillance and extended-duration studies remain essential to fully characterize their safety profile, particularly in high-risk populations and combination therapy scenarios. In conclusion, gepants offer a well-tolerated, non-vasoconstrictive alternative for migraine patients who require sustained treatment, representing a significant therapeutic advancement in migraine.

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Does Route of Administration Matter for Gepant Safety? A Comparative Disproportionality Analysis of Intranasal Zavegepant Using the FDA Adverse Event Reporting System
Martina Giacon, Salvatore Terrazzino
Journal of Pharmaceutical Innovation.2027;[Epub] CrossRef
Primary or Secondary Headache Disorders in Moyamoya Disease and Cerebral Infarction: Clinical Challenges and the Potential Role of Non-Vasoconstrictive Migraine Therapies
Soo-Jin Cho
Headache and Pain Research.2026; 27(1): 1. CrossRef
Exosomes from mesenchymal stem/stromal cells and their therapeutic role in osteoarthritic pain
Dimitrios Kouroupis, Stanislava Jergova, Jacqueline Sagen, Thomas M. Best
Journal of Experimental Orthopaedics.2026;[Epub] CrossRef
Real-world effectiveness and safety of CGRP monoclonal antibodies in elderly migraine patients: a Korean multicenter study
Soohyun Cho, Mi-Kyoung Kang, Heui-Soo Moon, Mi Ji Lee, Soo-Kyoung Kim, Hong-Kyun Park, Woo-Seok Ha, Min Kyung Chu, Young-Eun Gil, Byung-Su Kim, Soo-Jin Cho
The Journal of Headache and Pain.2026;[Epub] CrossRef
Gepants for the Treatment of Migraine in Children and Adolescents: Acute and Preventive Roles, Current Evidence, and Ongoing Trials
Ji-Hoon Na
Headache and Pain Research.2026; 27(3): 246. CrossRef
Integrative Migraine Therapy: From Current Concepts to Future Directions—A Plastic Surgeon’s Perspective
Cristian-Sorin Hariga, Eliza-Maria Bordeanu-Diaconescu, Andrei Cretu, Dragos-Constantin Lunca, Catalina-Stefania Dumitru, Cristian-Vladimir Vancea, Florin-Vlad Hodea, Stefan Cacior, Vladut-Alin Ratoiu, Andreea Grosu-Bularda
Medicina.2025; 62(1): 50. CrossRef

Headache as a Somatic Symptom in Pediatrics: Diagnosis and Integrated Management: Hye Eun Kwon; Headache Pain Res. 2025;26(3):193-199. Published online October 20, 2025; DOI: https://doi.org/10.62087/hpr.2025.0016

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Somatization—the expression of psychological distress through physical symptoms—presents a frequent and complex challenge in pediatric practice. Headache and dizziness are among its most common manifestations. This review addresses the diagnostic challenge of determining whether these symptoms indicate a primary headache disorder or reflect somatic symptom presentations. The difficulty becomes particularly evident when conditions manifest in severe or persistent forms, such as chronic primary headache (CPH) and somatic symptom and related disorders (SSRD), where clinical overlap is considerable and coexistence may occur. We first explore the shared pathophysiological mechanisms, emphasizing central sensitization as a unifying process. We then propose a clinical framework for differential diagnosis that includes careful evaluation of predisposing risk factors and contrasts the defined diagnostic criteria of CPH with the maladaptive psychological responses frequently observed in SSRD. Management strategies diverge pharmacologically but converge on key non-pharmacological approaches. For primary headaches, pharmacotherapy is primarily used for prophylaxis, although its efficacy remains limited in pediatric trials. In contrast, for somatic presentations, medication typically serves as an adjunctive treatment targeting comorbidities, while psychotherapy (particularly cognitive behavioral therapy [CBT]) functions as the cornerstone of care. Non-pharmacological interventions such as CBT and biofeedback are essential for improving functioning across both conditions. Therefore, effective management relies on a framework of comprehensive psychoeducation, holistic assessment, and integrated interdisciplinary care.

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Pediatric Headache in Korea: Beyond a Common Complaint to a Chronic Neurological Condition
Yun Jin Lee
Headache and Pain Research.2026; 27(1): 4. CrossRef

Editorial

Toward Precision Migraine Care: Genetics, Symptoms, and Big-Data-Driven Approaches: Soo-Jin Cho; Headache Pain Res. 2025;26(3):171-172. Published online October 17, 2025; DOI: https://doi.org/10.62087/hpr.2025.0017

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Cerebrovascular Hemodynamic Responses to Breath-Holding in Migraine: A Longitudinal Functional Near-Infrared Spectroscopy Study Comparing a Calcitonin Gene-Related Peptide Monoclonal Antibody and Oral Preventive Treatment
Dong A. Yea, Jong Kwan Choi, Yoo Hwan Kim
Headache and Pain Research.2026; 27(1): 52. CrossRef

Review Article

A Practical Approach to Headache in Moyamoya Disease: Mi-Yeon  Eun, Jin-Man Jung, Jay Chol Choi; Headache Pain Res. 2025;26(3):173-183. Published online October 17, 2025; DOI: https://doi.org/10.62087/hpr.2025.0011

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Moyamoya disease (MMD) is a progressive steno-occlusive cerebrovascular disorder of the intracranial internal carotid arteries characterized by fragile collateral vessel formation. Although ischemic and hemorrhagic strokes are the most widely recognized manifestations of MMD, headaches are common, often disabling, and remain underacknowledged. Epidemiological studies report headache in 17%–85% of MMD patients, with particularly high rates among pediatric patients. Clinically, headache phenotypes are diverse and include migraine-like headaches with or without aura, tension-type, cluster, and hemiplegic variants. These presentations often overlap with primary headache disorders, complicating the diagnosis and sometimes delaying the recognition of underlying MMD. The pathophysiology of MMD-related headaches is multifactorial, involving vascular stenosis, abnormal collateral circulation, altered hemodynamics, and neurogenic inflammation. Chronic hypoperfusion may lower the threshold for cortical spreading depression, contributing to migraine-like or aura-associated symptoms. Surgical revascularization has been reported to alleviate headaches in both pediatric and adult patients, but persistent or new headaches may occur postoperatively, and long-term outcomes remain inconsistent. Management often involves general analgesics such as acetaminophen and non-steroidal anti-inflammatory drugs, but vasoconstrictive agents (e.g., triptans and ergotamines) should be avoided. Lasmiditan, a non-vasoconstrictive 5-HT1F agonist, may represent a safer option for acute treatment, while the efficacy of other pharmacological agents remains unclear due to limited evidence. In conclusion, headaches in MMD are not only a frequent source of disability but also a potential clinical marker of disease activity. Wider recognition of their epidemiology, phenotypes, and mechanisms may improve the diagnosis, guide individualized treatment, and ultimately enhance quality of life for patients.

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Characteristics of sleep disturbance in Moyamoya disease
Mudassar Ahmad, James P. Klaas, Giuseppe Lanzino, Lorenzo Rinaldo, Stuart J. McCarter, Virend K. Somers, Erik K. St Louis, Diego Z. Carvalho
Sleep Medicine.2026; 138: 108684. CrossRef
Cerebrovascular Hemodynamic Responses to Breath-Holding in Migraine: A Longitudinal Functional Near-Infrared Spectroscopy Study Comparing a Calcitonin Gene-Related Peptide Monoclonal Antibody and Oral Preventive Treatment
Dong A. Yea, Jong Kwan Choi, Yoo Hwan Kim
Headache and Pain Research.2026; 27(1): 52. CrossRef
Headache and Stroke: A Review
Jong S. Kim
Headache and Pain Research.2026; 27(1): 7. CrossRef
Primary or Secondary Headache Disorders in Moyamoya Disease and Cerebral Infarction: Clinical Challenges and the Potential Role of Non-Vasoconstrictive Migraine Therapies
Soo-Jin Cho
Headache and Pain Research.2026; 27(1): 1. CrossRef

Correction

Erratum to “Premonitory Symptoms in Migraine: Implications for Disease Burden and Cognitive Impairment, with Some Promising Answers”: Utku Topbaş, Bahar Taşdelen, Nevra Öksüz Gürlen, Aynur Özge; Headache Pain Res. 2025;26(3):232-232. Published online August 20, 2025; DOI: https://doi.org/10.62087/hpr.2024.0031.e1; Corrects: Headache Pain Res 2025;26(2):130

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Original Articles

Clinical Characteristics of Migraine and Serum Beta-Endorphin Levels in Undergraduate Students in Osun State, Nigeria: Adebimpe Ogunmodede, Ahmed Idowu, Ahmad Sanusi, Uchenna Eke, Akintunde Adebowale, Michael Fawale, Morenikeji Komolafe; Headache Pain Res. 2025;26(2):162-170. Published online June 30, 2025; DOI: https://doi.org/10.62087/hpr.2025.0006

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Purpose: Migraine is a common neurological disorder diagnosed using the International Classification of Headache Disorders (ICHD). Beta-endorphin has pain-reducing properties and may serve as a future prognostic marker for migraine. This study aimed to assess the clinical characteristics of migraine and compare serum beta-endorphin levels in migraine patients and healthy controls among young undergraduate students.
Methods
This comparative cross-sectional study was conducted among undergraduate students at Obafemi Awolowo University, Nigeria. Fifty participants with migraine headaches were recruited using purposive sampling according to the ICHD-3 criteria. Healthy controls were recruited using convenience sampling and matched for age and sex. A study questionnaire was administered to all participants. Serum beta-endorphin concentrations in both migraineurs and healthy controls were measured using enzyme-linked immunosorbent assays. The beta-endorphin levels between migraine patients and healthy controls were compared using the Mann-Whitney U-test. The data were analyzed using SPSS version 26.0. A p-value of <0.05 was considered statistically significant.
Results
A total of 12 males and 38 females were recruited in both groups.The most commonly used medication for acute migraine treatment was paracetamol, while amitriptyline was the most frequently used prophylactic. Median serum beta-endorphin levels were significantly lower in the migraine group, at 385.4 pg/mL (328.5–423.4 pg/mL), compared to the control group, at 442.9 pg/mL (357.5–477.6 pg/mL) (p=0.01).
Conclusion
Serum beta-endorphin levels were significantly lower in young adults with migraine, suggesting a potential role for reduced endogenous analgesia in migraine pathophysiology. This supports the potential utility of beta-endorphin as a prognostic biomarker for migraine.

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Efficacy of aerobic training on resting-state brain wave, pain, sleep quality, and quality of life among university students with migraine symptoms: A randomized controlled trial
Kiruthika Selvakumar, Lee Fan Tan, Chai Nien Foo, Kit Mun Hou
Cephalalgia Reports.2026;[Epub] CrossRef

Validity of Migraine Diagnoses in Korean National Health Insurance Claims Data: Yoonkyung Chang, Soyoun Choi, Byung-Su Kim, Tae-Jin Song; Headache Pain Res. 2025;26(2):154-161. Published online June 19, 2025; DOI: https://doi.org/10.62087/hpr.2025.0004

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4 Citations

Abstract PDF Supplementary Material

Purpose: Accurate case identification using administrative datasets relies on diagnostic coding, yet these codes’ accuracy for migraine remains uncertain. This study aimed to validate the diagnostic accuracy of International Statistical Classification of Diseases and Related Health Problems 10th Revision (International Classification of Diseases, ICD-10) codes for migraine, migraine without aura (MOA), and migraine with aura (MA) in the Korean National Health Insurance Service database.
Methods
We retrospectively reviewed the electronic medical records of 500 patients (migraine [G43.X], 200; MOA [G43.0], 200; MA [G43.1], 100) from secondary and tertiary hospitals between January 2019 and December 2024. Diagnoses confirmed by headache specialists using the International Classification of Headache Disorders, third edition served as the gold standard. Validation metrics included the positive predictive value (PPV), negative predictive value, sensitivity, specificity, and the kappa statistic. Diagnostic accuracy was assessed based on ICD-10 claim frequency and improved by combining diagnostic codes with prescriptions for migraine medications.
Results
A single ICD-10 claim had a PPV of 74.00%. Accuracy improved significantly with increased claim frequency (≥3 claims: PPV, 81.14%; sensitivity, 98.61%; specificity, 28.26%), particularly when combined with medication prescriptions (≥3 claims with medication: PPV, 94.96%; sensitivity, 91.87%; specificity, 85.37%). MOA (≥3 claims with medication: PPV, 95.20%) and MA (≥3 claims with medication: PPV, 93.65%) showed similar trends. Excellent inter-rater reliability was observed (kappa, 0.806–0.951), with no significant accuracy differences between hospitals.
Conclusion
Employing multiple claims and prescriptions improved the accuracy of migraine diagnoses using ICD-10 codes, supporting the use of this method in epidemiological studies and health policy decisions.

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Natural Diagnostic Classes of Headache Disorders: Latent Class Analysis of a Population-Based Study
Wonwoo Lee, Seok-Jae Heo, Jungyon Yum, Min Kyung Chu
Headache and Pain Research.2026; 27(1): 30. CrossRef
Adverse pregnancy outcomes in women with migraine: A retrospective multicenter cohort study
Inbal Akavian, Roie Alter, Hadar Rosen, Itay Nitzan, Ronit Calderon‐Margalit, Doron Kabiri
Pregnancy.2026;[Epub] CrossRef
Association between Psoriasis and Migraine in a Nationwide Cross-Sectional Study in Korea
Woo-Seok Ha, Soohyun Cho
Headache and Pain Research.2026; 27(3): 204. CrossRef
Toward Precision Migraine Care: Genetics, Symptoms, and Big-Data-Driven Approaches
Soo-Jin Cho
Headache and Pain Research.2025; 26(3): 171. CrossRef

Availability, Accessibility, and Utilization of Diagnostics and Therapeutics for Spontaneous Intracranial Hypotension in Asia: Soyoun Choi, Woo-Seok Ha, Soo-Jin Cho, Aynur Özge, Betül Baykan, Esme Ekizoglu, Kiratikorn Vongvaivanich, Koichi Hirata, Linh Tuyen Nguyen, Mamoru Shibata, Min Kyung Chu, Otgonbayar Luvsannorov, Ryotaro Ishii, Shengyuan Yu, Shih-Pin Chen, Shuu-Jiun Wang, Takao Takeshima, Tsubasa Takizawa, Vinh Khang Nguyen, Wei-Ta Chen, Yen-Feng Wang, Soo-Kyoung Kim, Mi Ji Lee; Headache Pain Res. 2025;26(2):142-153. Published online June 16, 2025; DOI: https://doi.org/10.62087/hpr.2025.0005

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Purpose: Recent advances in imaging techniques have significantly enhanced the diagnosis of spontaneous intracranial hypotension (SIH). However, these developments have been reported mostly in Europe and the United States. This study aimed to evaluate the availability and utilization of diagnostic and treatment modalities for SIH in Asia, through a survey of regional headache specialists.
Methods
A literature search was conducted using PubMed, and members of the Asian Regional Consortium for Headache were contacted. Participants completed a two-step survey evaluating the availability, accessibility, and frequency of SIH diagnostic and treatment methods in their countries and institutions. Descriptive statistics were used to analyze the data.
Results
Twenty physicians from eight countries completed both rounds of the survey. Lumbar puncture, brain magnetic resonance imaging (MRI), and spinal MRI are widely available across Asia, but real-time imaging techniques—such as dynamic computed tomography myelography and digital subtraction myelography—that precisely localize cerebrospinal fluid leaks are less accessible. Blind or semi-targeted epidural blood patches (EBPs) are available at most centers, but are easily accessible in only about half of cases. Surgical interventions are rarely available.
Conclusion
Most diagnostic methods for SIH are available in Asia, despite some regional disparities. The utilization of EBP and surgical interventions remains somewhat limited. This highlights the need for greater awareness and standardization of diagnostic methods in Asia.

Citations

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Temporal and regional trends in the diagnosis and treatment of spontaneous intracranial hypotension: a systematic review
Woo-Seok Ha, Soyoun Choi, Mi-Kyoung Kang, Hye Yun Kim, Soo-Jin Cho, Soo-Kyoung Kim, Mi Ji Lee
The Journal of Headache and Pain.2026;[Epub] CrossRef
Diagnostic Value of Flow-Void Sign for Localizing Ventral Dural Defects in Spine MRI
Soo-Im Jang, Soyoun Choi, Seung Ae Kim, Hoe Jong Jeong, Ja-Young Choi, Mi Ji Lee
Journal of Clinical Neurology.2026; 22(3): 364. CrossRef
Current Concepts in the Diagnosis and Management of Spontaneous Intracranial Hypotension
Woo-Seok Ha, Min Kyung Chu
Journal of the Korean Neurological Association.2026; 44(2): 110. CrossRef
Surgical Treatment of Spontaneous Intracranial Hypotension: Clinical Characteristics and Outcomes in a Surgically Treated Cohort of Type 1 and Type 3 Leaks
Woo-Seok Ha, Hyun Woong Mun, Soomi Cho, Chang Kyu Lee, Dong Ah Shin, Seong Yi, Keung Nyun Kim, Min Kyung Chu, Yoon Ha
Journal of Clinical Medicine.2026; 15(13): 4972. CrossRef
Recommendations for the Management of Spontaneous Intracranial Hypotension With Spinal Longitudinal Epidural CSF Collection
Soyoun Choi, Ian Carroll, Deborah I. Friedman, Peter G. Kranz, Eugene Lee, Manjit Matharu, Simy Parikh, Henrik W. Schytz, Marcio Nattan Portes Souza, Yen-Feng Wang, Hsiangkuo Yuan, Mi Ji Lee
Neurology.2026;[Epub] CrossRef

Review Article

Vestibular Migraine: Challenges in Diagnosis and Management: Byung-Kun Kim; Headache Pain Res. 2025;26(2):106-115. Published online June 11, 2025; DOI: https://doi.org/10.62087/hpr.2025.0001

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562 Download
4 Citations

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Vestibular migraine (VM) remains a clinical challenge due to its heterogeneous presentation and the frequent absence of typical migraine features during vestibular episodes. Although many studies have adopted the diagnostic criteria defined by the International Classification of Headache Disorders (ICHD), interpretation of findings is often complicated by variability in how these criteria are applied across studies. VM is frequently underdiagnosed or misdiagnosed, owing to its clinical overlap with other vestibular disorders. This review provides a comprehensive overview of the epidemiology, diagnostic criteria, differential diagnosis, and treatment strategies for VM. Particular emphasis is placed on distinguishing VM from other causes of vertigo to support accurate diagnosis and tailored management. By synthesizing current evidence, this review aims to improve clinical recognition, diagnostic precision, and therapeutic outcomes for patients with this under-recognized and often debilitating condition.

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Vestibular Evoked Myogenic Potential in Vestibular Migraine: A Systematic Review of Diagnostic Utility
Mayur Bhat, Krithi Rao, Sinchana Hegde, Kaushlendra Kumar, Aditya Khandagale, KM Prajwal, Shezeen Abdul Gafoor
Audiology Research.2026; 16(1): 11. CrossRef
Clinical heterogeneity in acute vestibular migraine attacks
Mahmoud Mohamed Mahrous, Yomna Ahmad El-Khattib
Hearing Balance and Communication.2026; 24(2): 83. CrossRef
Cognitive impairment in vestibular migraine: a PubMed-based systematic review and meta-analysis
Meiqi Di, Lingling Hu, Chaosheng Li, Xiaojing Yin, Shuhua Gui, Likun Han
Frontiers in Neurology.2026;[Epub] CrossRef
Toward Precision Migraine Care: Genetics, Symptoms, and Big-Data-Driven Approaches
Soo-Jin Cho
Headache and Pain Research.2025; 26(3): 171. CrossRef

Editorial

Tension-Type Headache and Primary Stabbing Headache: Primary Headaches Beyond Migraine: Mi-Kyoung Kang; Headache Pain Res. 2025;26(2):89-90. Published online June 5, 2025; DOI: https://doi.org/10.62087/hpr.2025.0007

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Results of the observational program CITOTREK (use of the drug CITOflavin in Tablets) in patients with tension headaches against the backgRound of asthenic syndromE taKing into account comorbidity
M.V. Putilina, N.I. Shabalina, I.A. Blinova
S.S. Korsakov Journal of Neurology and Psychiatry.2025; 125(10): 104. CrossRef

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