Headache and Pain Research

Volume 24(2); December 2023

Review Articles

Treatment Strategies of Medication Overuse Headache: Mi-Kyoung Kang, Jong-Hee Sohn; Korean J Headache. 2023;24(2):33-38. Published online December 31, 2023

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Abstract PDF: Medication overuse headache (MOH) is a common secondary headache disorder in which chronic headaches develop or worsen due to frequent and excessive intake of medications used for acute headache treatment. While the concept of MOH is widely recognized among headache specialists, ongoing debates exist regarding its causes, diagnostic criteria, and treatment strategies. Treating MOH has traditionally been challenging, and there is currently no universal consensus on how to effectively manage patients with MOH. Furthermore, a specific treatment approach based on well-powered randomized trials is still lacking. The treatment strategy for MOH typically involves several steps: patient education and counseling, withdrawal of overused medications, preventive drug therapy, and non-pharmacological prevention. It is recommended that all patients discontinue the overused medication, which can be carried out on an outpatient or inpatient basis. Additionally, topiramate, Botox, and anti-calcitonin gene-related peptide monoclonal antibodies have shown potential in reducing headache and migraine frequency, as well as acute drug consumption, even without active drug withdrawal. However, many aspects of MOH management require further investigation through properly designed and adequately powered randomized controlled trials.

Diagnosis and Treatment of Hemicrania Continua, Paroxysmal Hemicrania, Short-lasting Unilateral Neuralgiform Headache Attacks: Sang-Hwa Lee, Mi-Kyoung Kang, Soo-Jin Cho; Korean J Headache. 2023;24(2):39-44. Published online December 31, 2023

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Abstract PDF: Chronic paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks, and hemicrania continua are rare headache disorders characterized by severe unilateral headache accompanied by ipsilateral autonomic symptoms. Accurate diagnosis and specific treatment approaches for these conditions are crucial for appropriate management. This article covers the clinical features, diagnostic criteria, and treatment strategies of each disorder, aiming to differentiate them from other major headaches and provide targeted treatment strategies to improve patient outcomes.

Updated Treatment of Trigeminal Autonomic Cephalalgias: So Youn Choi, Michelle Sojung Youn, Mi Ji Lee; Korean J Headache. 2023;24(2):45-49. Published online December 31, 2023

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Abstract PDF: Trigeminal Autonomic Cephalalgia (TAC) encompasses cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks (SUNHA), and hemicrania continua. The treatment of cluster headache consists of acute therapy and preventive treatment. The available options for acute treatment in South Korea include high-flow O₂ inhalation, zolmitriptan oral medication, and intranasal lidocaine spray. In the transitional phase of cluster headache, oral steroids and suboccipital steroid injections are commonly used. Verapamil and lithium have been widely used as preventive medications, but recently, galcanezumab, a monoclonal antibody targeting calcitonin gene-related peptide, has emerged as a recognized preventive treatment for cluster headache. In addition, neuromodulation techniques, such as noninvasive vagus nerve stimulation, sphenopalatine ganglion stimulation, occipital nerve stimulation, and deep brain stimulation, are also available for the treatment of cluster headache. Paroxysmal hemicrania and hemicrania continua are absolutely responsive to indomethacin; however, when indo methacin is contraindicated, alternative treatments are necessary. Reported alternatives include topiramate, vagus nerve stimulation, verapamil, and carbamazepine for paroxysmal hemicrania, and topiramate, gabapentin, and neurostimulation for hemicrania continua. Treatment options for SUNHA are limited, but short-term preventive approaches such as intravenous lidocaine, as well as the use of lamotrigine for preventive treatment, can be considered.

Migraine and Stroke: Myoung-Jin Cha, Ha Yeun Oh, Jiyoung Kim; Korean J Headache. 2023;24(2):50-55. Published online December 31, 2023

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Abstract PDF: The relationship between migraine and stroke is intricate and bidirectional. Migraine, a neurological disorder characterized by severe headaches and associated symptoms, exhibits some similarities in presentation with stroke. Conversely, stroke can at times mimic migraine symptoms. Migrainous infarction is directly associated with stroke. Specifically, migraine with aura has been linked to an increased risk of ischemic stroke. Migraine with aura and the frequency of headaches are considered risk factors for stroke. Moreover, migraine is associated with subclinical infarct-like brain lesions and white matter changes. Additionally, some genetic disorders predispose individuals to develop both migraine and stroke. In this review, we aim to investigate the relationship between migraine and stroke.

New Targeted Drugs for Acute Treatment of Migraine: Heui-Soo Moon, Pil-Wook Chung, Byung-Kun Kim; Korean J Headache. 2023;24(2):56-65. Published online December 31, 2023

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Abstract PDF: Acute migraine treatments primarily aim to relieve headache pain and address accompanying symptoms such as photophobia, phonophobia, and nausea. Triptans have traditionally been the first-line treatment for moderate to severe migraine attacks. Nevertheless, they have several limitations, such as causing temporary vasoconstriction of blood vessels, contraindications in patients with cardiovascular issues, and distinctive side effects like chest tightness. Medication overuse is another concern with triptans, prompting research into new antimigraine drugs targeting calcitonin gene-related peptide (CGRP) or 5-HT_1F receptors. Lasmiditan, an agonist at the 5-HT_1F receptor, has emerged as a safe and effective option for abortive treatment in acute migraine attacks. It lacks the vasoconstrictive effects associated with triptans, making it a safer choice for individuals with contraindications to triptans. However, it may lead to central nervous system-related adverse effects, particularly dizziness and paresthesia. Gepants, which are CGRP antagonists, offer an innovative approach by targeting CGRP receptors which is believed to be central in migraine pathophysiology. These medications have demonstrated efficacy in alleviating migraine symptoms, providing alternatives to traditional treatments like triptans and ergots. Ubrogepant and rimegepant are the first approved oral gepants for acute migraine treatment, while Zavegepant is the first approved intranasal gepant. The most common treatment-related adverse events are gastrointestinal symptoms, including nausea. No vascular or hepatic concerns have emerged to date. In this review, we delve into the development of ditans and gepants for acute migraine treatment in adults and discuss their potential advantages and disadvantages in clinical use.

Original Articles

A Survey on Headache Education Curriculum in College of Dentistry: Jin Kyu Kang, Ji-Won Ryu, Seong-Taek Kim; Korean J Headache. 2023;24(2):66-69. Published online December 31, 2023

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Abstract PDF: Background
Headache is a common pain condition encountered in clinical practice. Many patients visit a doctor or dentist complaining of headaches accompanied by toothaches or facial pain. However, it has been reported that education on headaches is insufficient in medical schools, which is believed to be a more serious problem in dental schools.
Methods
We surveyed the current status of headache education curriculum in 11 dental schools in Korea.
Results
In most dental schools, headache education was provided as part of orofacial pain course within the oral medicine program. Only two universities covered headache as an in-depth postgraduate course. Lectures were delivered by oral medicine faculty, and only one university included a neurologist as part of the team teaching. Dental textbooks still described headaches based on the 2^nd edition of the International Classification of Headache Disorders.
Conclusion
Currently, headache education in dental schools in Korea is inadequate and outdated. Considering the specificity of dentists who are in charge of pain in oral and facial region, continuous discussions and mutual cooperation with the neurology department are necessary to ensure sufficient education related to headaches during the undergraduate course.

Secular Trend of Sex Ratio in Participants under Randomized Controlled Trials for Cluster Headache: Pil-Wook Chung, Heui-Soo Moon; Korean J Headache. 2023;24(2):70-76. Published online December 31, 2023

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Abstract PDF: Background
Although cluster headache (CH) is well known as a disorder of predominantly young males, the male to female ratio decreased from 5-7:1 before 1980s to -2:1 in the 2000s and afterward in Western observational studies. It is unclear whether this represents a true rise of CH in women or better recognition of CH in women. We sought to assess whether the sex ratio of CH were changing or not in randomized controlled trials (RCTs) over time in accordance with observational studies.
Methods
We included RCTs regarding pharmacologic medication, as well as procedural and surgical treatment, devices. Time trend of sex ratio was compared among 3 different publication era (1985-2000 vs 2001-2010 vs 2011-). Sex ratio between different cluster headache type (Episodic vs Chronic) was also compared.
Results
22 acute treatment trials and 25 preventive treatment trials were initially selected for inclusion. 5 acute treatment trials and 10 preventive treatment trials were excluded due to small sample size (n<20) and/or no demographic information. All studies were underwent in western countries. Of 32 trials finally included, 10 studies were published between 1985 to 2000 (1^st era), 8 studies from 2001 to 2010 (2^nd era), 14 studies after 2010 (3^rd era). Of the 2,476 patients, 80% were male. Secular tendency of decreasing male predominance was shown over time. 542 of 623 patients (87%) were male in 1^st era, while 83% were male in 2^nd era, and 75.3% were male in 3^rd era (p<0.001). Male to female ratio was 6.7:1 in 1^st era, 4.9:1 in 2^nd era, and 3:1 in 3^rd era. In chronic CH, 28% of subjects were female, while in episodic CH, 14.6% were female (p<0.001)
Conclusions
As suggested by observational and registry data, the population enrolled in the RCT also exhibited a decreasing trend in male predominance over time in CH.

Case Reports

Spontaneous Intracranial Hypotension after Airplane Travel: Ho Jin Hwang, Jiyun Park, Sun Jae Moon, Dong Hyun Hwang, Kyongha Baek, Young Seo Kim; Korean J Headache. 2023;24(2):77-79. Published online December 31, 2023

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Abstract PDF: Spontaneous intracranial hypotension usually manifests orthostatic headache caused by cerebrospinal fluid leakage without procedure or trauma to meninges. There was temporal relationship between intracranial hypotension and various precipitating factors such as positional changes, valsalva maneuver, minor trauma and only rarely airplane travel. Here, we report the first korean case of spontaneous intracranial hypotension after airplane travel. A 37-year-old woman presented with orthostatic headache after airplane travel. Her cerebrospinal fluid pressure is 55 mmCSF and cervical spinal level of cerebrospinal fluid leakage confirmed by cisternography. Her symptoms resolved after the epidural blood patch and she was later discharged without any complications.

Unilateral Retro-orbital Headache Secondary to Septic Cavernous Sinus Thrombosis: A Case Report: Sumin Kim, Sorae Lee, Jun-Sang Sunwoo; Korean J Headache. 2023;24(2):80-83. Published online December 31, 2023

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Abstract PDF: Septic cavernous sinus thrombosis (SCST) is a rare but fatal central nervous system infectious disease affecting the cavernous sinuses. Here, we report a case of 51-year-old woman presenting with new-onset unilateral retro-orbital headache lasting for 3 weeks and subsequent ipsilateral abducens nerve palsy. Brain magnetic resonance imaging revealed enlargement of the cavernous sinus with dural enhancement and ring-enhancing abscess in the adjacent temporal lobe. Although blood and cerebrospinal fluid cultures were negative, the patient was successfully treated with empirical antibiotic therapy. Although SCST is a possible cause of painful ophthalmoplegia, it should be kept in mind that in the early stage it may present only with headache without ocular symptoms.

Neuroimage

Invasive Aspergillosis Manifesting as Painful Ophthalmoplegia: Sorae Lee, Sumin Kim, Sanggyu Han, So-Ei Ann, Pil-Wook Chung, Bum Chun Suh, Jun-Sang Sunwoo; Korean J Headache. 2023;24(2):84-86. Published online December 31, 2023

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