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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
- 522 View
- 10 Download
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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.
Original Article
- Evidence-Based Recommendations on Pharmacologic Treatment for Migraine Prevention: A Clinical Practice Guideline from the Korean Headache Society
- Byung-Su Kim, Pil-Wook Chung, Jae Myun Chung, Kwang-Yeol Park, Heui-Soo Moon, Hong-Kyun Park, Dae-Woong Bae, Jong-Geun Seo, Jong-Hee Sohn, Tae-Jin Song, Seung-Han Lee, Kyungmi Oh, Mi Ji Lee, Myoung-Jin Cha, Yun-Ju Choi, Miyoung Choi
- Headache Pain Res. 2025;26(1):5-20. Published online January 16, 2025
- DOI: https://doi.org/10.62087/hpr.2024.0019
- 17,296 View
- 370 Download
- 17 Citations
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Abstract
PDF
- Purpose: The aim of this clinical practice guideline (CPG) from the Korean Headache Society is to provide evidence-based recommendations on the pharmacologic treatment for migraine prevention in adult migraine patients.
Methods
The present CPG was developed based on the guideline adaptation methodology through a comprehensive systematic search for literature published between January 2012 and July 2020. The overall quality of the CPGs was assessed using the Korean version of the Appraisal of Guidelines for Research and Evaluation II tool. High-quality CPGs were adapted to make key recommendations in terms of strength (strong or weak) and direction (for or against).
Results
The authors selected nine available high-quality guidelines throughout the process of assessment of quality. Regarding oral migraine preventive medications, propranolol, metoprolol, flunarizine, sodium divalproex, and valproic acid are recommended to adult patients with episodic migraines based on high-quality evidence (“strong for”). Topiramate can be recommended for either episodic or chronic migraine (“strong for”). For migraine prevention using calcitonin gene-related peptide monoclonal antibodies, galcanezumab, fremanezumab, erenumab, and eptinezumab are recommended for adult patients with either episodic or chronic migraine on the basis of high-quality evidence (“strong for”). OnabotulinumtoxinA is recommended for adult patients with chronic migraine based on high-quality evidence (“strong for”). Last, frovatriptan, naratriptan, and zolmitriptan are recommended for short-term prevention in women with menstrual migraine (“strong for”).
Conclusion
In the present CPG, the authors provide specific, straightforward, and easy-to-implement evidence-based recommendations for pharmacologic migraine prevention. Nevertheless, these recommendations should be applied in real-world clinical practice based on optimal individualization. -
Citations
Citations to this article as recorded by
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Infection & Chemotherapy.2025; 57(4): 478. CrossRef
- Alcohol-Induced Headache: A Narrative Review Based on Migraine Pathophysiology
- Clinical Practice Guideline of Pharmacologic Treatment for Migraine Prevention in Adults 2021: The Committee of Clinical Practice Guideline of the Korean Headache Society
- Kim Byung-Su, Jae Myun Chung, Pil-Wook Chung, Kwang-Yeol Park, Jin-Young Ahn, Heui-Soo Moon, Hong-Kyun Park, Dae Woong Bae, Jong-Geun Seo, Jong-Hee Sohn, Tae-Jin Song
- Published online December 31, 2021
- 1,565 View
- 139 Download
- A Case of Superior Orbital Fissure Syndrome Attributed to Sinusitis Presenting Unilateral Throbbing Headache
- Byung-Su Kim, Byung-Kun Kim, Soo-Kyoung Kim, Jae-Moon Kim, Heui-Soo Moon, Kwang-Yeol Park, Jong-Hee Sohn, Tae-Jin Song, Min Kyung Chu, Myoung-Jin Cha, Soo-Jin Cho, J
- Published online December 31, 2017
- 1,010 View
- 111 Download
- The Frequency and Characteristics of Other Primary Headache Disorders in First-Visit Headache Patients in Korea: A Multicenter Study
- Myoung-Jin Cha, Byung-Kun Kim, Byung-Su Kim, Jong-Hee Sohn, Soo-Kyoung Kim, Heui-Soo Moon, Tae-Jin Song, Jae-Moon Kim, Jeong Wook Park, Min Kyung Chu, Kwang-Yeol Park
- Published online December 31, 2017
- 989 View
- 89 Download
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