Headache and Pain Research

Volume 27(2); June 2026

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

418 View
7 Download

PDF

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

184 View
5 Download

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

763 View
7 Download

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.

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

163 View
4 Download

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.

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

348 View
6 Download

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.

Original Articles

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

265 View
11 Download

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.

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

397 View
12 Download

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.

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

97 View
2 Download

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.

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

86 View
1 Download

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.

Letters 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

275 View
3 Download

PDF

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

308 View
2 Download

PDF

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

287 View
2 Download

PDF

First
Prev
Page of 1
Next
Last

Current issue