Headache and Pain Research

Review Articles

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.

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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3 Citations

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

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.

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