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Diagnosis challenges and accessibility barriers to migraine management in Southeast Asia: results from the South-East Asia Local breAch on MigraiNe Treatment (SEALANT) study
(2026-12-01)
Rattanawong, Wanakorn
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Hiransuthikul, Akarin
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Anukoolwittaya, Prakit
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Pongpitakmetha, Thanakit
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Thanprasertsuk, Sekh
Background: Migraine is one of the leading causes of disability among all neurological diseases, yet major gaps persist in diagnosis and access to effective treatment, particularly in low- and middle-income regions. Southeast Asia and East Asia are characterised by marked socioeconomic diversity, variable healthcare infrastructure, and limited availability of migraine-specific therapies. We aimed to assess physician-reported barriers to migraine diagnosis and management across Southeast Asian and East Asian countries. Methods: The South-East Asia Local breAch on MigraiNe Treatment (SEALANT) study was a multinational, cross-sectional, web-based survey conducted between Nov 1, 2024, and Aug 31, 2025. Physicians involved in migraine care from Laos, Indonesia, Malaysia, the Philippines, Singapore, Taiwan, and Thailand were eligible. Survey domains included diagnostic barriers, clinic accessibility, acute and preventive treatment practices, awareness of medication overuse headache, access to calcitonin gene-related peptide (CGRP)–targeted therapies, and migraine-related stigma. Countries were categorised by World Bank income classification. Data were analysed descriptively, and comparisons were made across income groups. All results are based on physicians’ perceptions of routine clinical practice rather than objectively verified patient-level data. Results: A total of 686 physicians participated (mean age 39.0 years [SD 9.9]), of whom 79.8% were neurologists. Overall, 70.0% of respondents reported an insufficient number of neurology/headache clinics, increasing to 87.2% in lower-middle-income countries. Physicians reported that approximately 60.0% of patients were correctly diagnosed with migraine before specialist consultation, while 44.9% were perceived to experience diagnostic delays exceeding one year. According to physician reports, acute migraine management relied predominantly on non-specific analgesics, with opioids remaining widely available and prescribed across all income settings. Reported use of migraine-specific acute therapies and preventive treatments was limited. Although CGRP-targeted preventive therapies were widely regarded by physicians as effective (77.1%), many perceived that these treatments should not yet be reimbursed. Conclusion: Substantial and inequitable gaps persist in migraine diagnosis and management across Southeast Asia and East Asia, as perceived by physicians, driven by shortages of specialist services, delayed diagnosis, reliance on non-specific treatments, and restricted access to migraine-specific therapies. Addressing migraine as a public health priority through health-system strengthening, education, and equitable access to evidence-based treatments is essential to reduce disability in the region.
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Correction: Diagnosis challenges and accessibility barriers to migraine management in Southeast Asia: results from the South-East Asia Local breAch on MigraiNe Treatment (SEALANT) study (The Journal of Headache and Pain, (2026), 27, 1, (47), 10.1186/s10194-026-02295-1)
(2026-12-01)
Rattanawong, Wanakorn
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Hiransuthikul, Akarin
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Anukoolwittaya, Prakit
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Pongpitakmetha, Thanakit
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Thanprasertsuk, Sekh
In the section Survey and outcomes of this article, the components of the questionnaire were incorrectly labeled using the manuscript-style headings “Introduction,” “Methods,” “Results,” “Discussion,” and “Conclusion.” These terms were intended solely to denote internal sections of the questionnaire and do not correspond to the standard structural sections of the manuscript. To avoid confusion, these labels have been replaced with “Section 1,” “Section 2,” “Section 3,” “Section 4,” and “Section 5,” respectively. The correct and incorrect version of the text is presented below and the original article has been corrected. The survey comprised five main sections, each designed to explore different aspects of migraine care and physician perspectives. Section 1 collected demographic data. Section 2 focused on barriers to migraine diagnosis, covering issues such as diagnostic accuracy, time to diagnosis, hospital workload, and use of headache diaries and patient education. Section 3 explored acute migraine treatment, including medication availability, the proportion of patients using acute medications, issues of medication underuse (timing and efficacy), and awareness of MOH. Section 4 explored preventive treatment, including access to preventive medications, availability of calcitonin gene-related peptide (CGRP)–targeted therapies, and physicians’ views on their use. Section 5 explored migraine-related stigma and its impact on patients’ quality of life; these findings will be reported separately. The survey comprised five main sections, each designed to explore different aspects of migraine care and physician perspectives. Section “Introduction” collected demographic data. Section “Methods” focused on barriers to migraine diagnosis, covering issues such as diagnostic accuracy, time to diagnosis, hospital workload, and use of headache diaries and patient education. Section “Results” explored acute migraine treatment, including medication availability, the proportion of patients using acute medications, issues of medication underuse (timing and efficacy), and awareness of MOH. Section “Discussion” explored preventive treatment, including access to preventive medications, availability of calcitonin gene-related peptide (CGRP)–targeted therapies, and physicians’ views on their use. Section “Conclusion” explored migraine-related stigma and its impact on patients’ quality of life; these findings will be reported separately.
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Expert consensus on gepants for acute and preventive treatment of migraine in Thailand
(2025-12-01)
Anukoolwittaya, Prakit
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Rattanawong, Wanakorn
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Vongvaivanich, Kiratikorn
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Pongpitakmetha, Thanakit
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Thanprasertsuk, Sekh
Introduction: Gepants, a calcitonin gene-related peptide (CGRP) receptor antagonist, is a class of migraine therapeutic options with extensive evidence supporting a favorable efficacy and safety profile. However, as a novel class of medication in Thailand, specific guidelines or recommendations regarding rational drug use are currently unavailable. This could hinder physicians from utilizing the medications for eligible patients and prevent pharmacists from providing information to physicians and patients. Main body: In order to develop consensus-based statement recommendations, a modified Delphi approach was employed, which included two rounds of surveys, discussions, and voting. General recommendations were made, as well as specific recommendations of gepants in both acute and preventive treatment roles. Additionally, clinical settings where gepants could be suitable options were identified, along with the recommendations for their use in special populations and relevant precautions. Conclusion: Gepants can serve as both acute and preventive therapy for migraines. They provide an alternative to first-line therapies for patients with limitations to conventional agents, including contraindications or intolerance. Gepants can be utilized as monotherapy or in combination with other treatment approaches. Optimal prescribing practices for eligible patients could ensure that patients receive maximum benefit with minimal risk.
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EEG patterns in each phase of hemiplegic migraine: a systematic review and pooled prevalence meta-analysis
(2025-12-01)
Kedgan, Penpisut
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Anukoolwittaya, Prakit
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Surawattanawong, Totsapol
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Thanprasertsuk, Sekh
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Rattanawong, Wanakorn
Introduction: Hemiplegic migraine (HM) is a rare subtype of migraine with aura, and its pathophysiology is similar to that of migraine with aura, primarily involving cortical spreading depression. Electroencephalography (EEG) may serve as a valuable tool for investigating brain function in patients with hemiplegic migraine. Therefore, this study aims to synthesize available evidence through a systematic review and pooled prevalence meta-analysis to assess the types of EEG abnormalities observed in each migraine phase in patients with hemiplegic migraine and to estimate the prevalence of EEG abnormalities during the interictal period. Method: We searched PubMed, Scopus, and Cochrane up to January 2025 and included articles, including case reports, case series, and retrospective studies that reported EEG abnormalities in hemiplegic migraine. The prevalence of abnormal EEG during the interictal phase was analyzed through pooled data analysis. Result: A total of 40 articles involving 65 patients were included in the analysis. The most common EEG abnormality During the aura phase was low-amplitude activity affecting the hemisphere contralateral to the hemiparesis, observed in 71.4% (5/7) of cases. Similarly, During the headache and post-headache phases, the most frequently observed EEG abnormality was medium- to high-amplitude slowing, particularly in the hemisphere contralateral to the hemiparesis, occurring in 54.9% (28/51) and 37.5% (9/24) of cases, respectively. Meanwhile, 78.8% (26/33) of patients’ EEG recordings during the interictal phase were normal. Conclusion: This study found that the most common EEG abnormality during the aura phase was low-amplitude activity in the hemisphere contralateral to the hemiparesis, while during the headache and post-headache phases, medium- to high-amplitude focal slowing was frequently observed in the same hemisphere. EEGs during the interictal phase were mostly normal. These findings provide an overview of characteristic EEG patterns in each phase of hemiplegic migraine and may support the hypothesis that widespread cortical spreading depression precedes subcortical propagation.
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CGRP-targeted therapy fulfilling the treatment gap in medication-underuse setting: a retrospective cohort study at a tertiary headache center in Thailand, a lower-middle-income country
(2025-12-01)
Roongrojwittayakul, Sirawit
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Anukoolwittaya, Prakit
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Hiransuthikul, Akarin
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Pongpitakmetha, Thanakit
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Thanprasertsuk, Sekh
Background: Migraine preventive treatment is essential to reducing the burden of disease. However, discontinuation of oral migraine preventive medications (OMPMs) remains common due to suboptimal efficacy and tolerability, especially in lower-middle-income countries, which may contribute to migraine progression—a situation that has led to the introduction of the concept of “Medication Underuse Headache”. The calcitonin gene-related peptide monoclonal antibody (CGRP mAbs) might close the gap in this situation. This study aimed to investigate the treatment patterns of migraine preventive medications over six months at a tertiary headache center in Thailand and to explore the association between each preventive medication class and discontinuation rates. Methods: A single-center retrospective cohort study was conducted between 2021 and 2023. Adult patients who were diagnosed with migraine and received at least one preventive medication at their first visit to the Headache Clinic at King Chulalongkorn Memorial Hospital were included, with a minimum follow-up period of six months. The primary outcome was the discontinuation of any migraine preventive medication from the baseline regimen during follow-up visits. A multivariable Cox regression model, adjusted for sex, age, and diagnosis, was used to explore baseline factors associated with the discontinuation of preventive migraine medications. Results: Among the 100 eligible patients (mean age [SD]: 39.6 [14.4] years; 87.0% female), 41.0% (41/100) discontinued at least one preventive medication, most commonly due to intolerance to side effects (53.7%, 22/41) and lack of treatment effectiveness (34.1%, 14/41). The highest discontinuation rates were observed with serotonin norepinephrine reuptake inhibitors at 53.8% (7/13), calcium channel blockers at 37.5% (6/16), and beta-blockers at 25.6% (11/43). Notably, no patients discontinued CGRP mAbs. Patients using CGRP mAbs at baseline had a significantly higher rate of discontinuing at least one other oral preventive medication compared to those who did not use CGRP mAbs: 31.7% vs. 25.4% at month 3, and 55.4% vs. 33.4% at month 6 (p = 0.04). After adjustment, baseline use of CGRP mAbs was significantly associated with an increased risk of discontinuing at least one medication in the regimen (adjusted odds ratio 2.16; 95% CI: 1.16 to 4.03, p = 0.02). Conclusion: Discontinuation of preventive migraine treatment remains a significant issue in Thailand. CGRP mAbs were associated with higher treatment persistence and may help reduce polypharmacy in migraine management.
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Medication underuse in real-life practice: the impact of galcanezumab towards achieving very low frequency episodic migraine in a southeast Asian middle-income nation
(2025-12-01)
Rattanawong, Wanakorn
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Anukoolwittaya, Prakit
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Hiransuthikul, Akarin
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Pongpitakmetha, Thanakit
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Trisataya, Auranee
Background: Migraine progression, particularly from episodic to chronic migraine (CM), increases disease burden and healthcare costs. Understanding the new concept of “Medication Underuse Headache” should encourage the health care provider to consider early intervention with calcitonin gene-related peptide (CGRP) monoclonal antibodies. Galcanezumab given early in the course of the disease, may prevent migraine chronification and have a robust response, moreso than when initiated in later stages of migraine. We aimed to determine the efficacy of galcanezumab in achieving very low-frequency episodic migraine (VLFEM) among patients with high-frequency episodic migraine (HFEM) and CM in a real world-setting in Thailand. Methods: A single-center, retrospective real-world, cohort study was conducted between 2023 and 2024. Adults aged 18 years or more who were diagnosed with HFEM or CM were included in this trial and categorized into two groups: galcanezumab and oral migraine preventive medication (OMPM). In the galcanezumab group, oral preventive medications were slowly tapered off within 3 months. The primary outcome was the differences in percentage of patients achieving VLFEM at months 3 and 6 between the two groups. Secondary outcomes included the differences in migraine class improvement, sustained response, and headache day reduction. Results: A total of 62 patients (31 in each group) were included: median age was 36.5 (IQR: 29.0–48.0) and 82% were female. There were no significant differences in the baseline demographic features between the two groups. The cumulative incidence of patients achieving VLFEM was significantly higher among the galcanezumab group compared to OMPM group (45.2% vs. 19.4% at month 3 and 52.9% vs. 32.4% at month 6, p = 0.03). After 6 months of follow-up, patients with HFEM who received galcanezumab were significantly more likely to achieve any improvements in migraine class compared to those who received OMPM (92.9% vs. 46.7%, p = 0.01). Among 15 patients who achieved VLFEM at month 3, 81.8% (9/11) of those who received galcanezumab and 50.0% (2/4) of those who received OMPM were able to sustain VLFEM at month 6. Conclusions: This study emphasizes the benefit of early anti-CGRP therapy initiation, especially in patients with fewer headache days, and highlights the need for accessible migraine-specific treatments in low- to middle-income countries.
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Correction to: Filling the data gap on CGRP mAb therapy in low- to middle-income countries in Southeast Asia: insights from a real-world study in Thailand (The Journal of Headache and Pain, (2024), 25, 1, (150), 10.1186/s10194-024-01859-3)
(2025-12-01)
Anukoolwittaya, Prakit
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Hiransuthikul, Akarin
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Pongpitakmetha, Thanakit
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Thanprasertsuk, Sekh
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Rattanawong, Wanakorn
In this article reference 13 was Asawavichienjinda T, Imruetaijaroenchoke W, Phanthumchinda K (2020) Thai-version Migraine Disability Assessment (MIDAS) questionnaire: concurrent validity, test-retest reliability, internal consistency, and factors predictive for migraine-related disability. Asian Biomed (Res Rev News) 14(4):139–150 but it should have been Vongvaivanich K, Yongprawat T, Jindawong N, Chansakul C (2018) Test-Retest Reliability of the Thai Migraine Disability Assessment (Thai-MIDAS) Questionnaire in Thai Migraine Patients. Bangk Med J 14(1):10–10. The original article has been updated. The authors would like to apologize for any inconvenience caused.
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Filling the data gap on CGRP mAb therapy in low- to middle-income countries in Southeast Asia: insights from a real-world study in Thailand
(2024-12-01)
Anukoolwittaya, Prakit
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Hiransuthikul, Akarin
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Pongpitakmetha, Thanakit
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Thanprasertsuk, Sekh
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Rattanawong, Wanakorn
Background: Most real-world data on CGRP mAbs have been published from high-income countries such as the USA, Western countries, Japan, Korea, and Singapore. However, data from low- and middle-income countries in Southeast Asia is lacking. This is the first real-world study from Thailand to describe the efficacy of CGRP mAbs therapy in migraine patients and to analyze the response trends between episodic migraine and chronic migraine. Methods: We conducted a single-center, real-world retrospective chart review study with an observation period of 6 months after CGRP mAbs initiation. We aim to compare treatment responses to CGRP mAbs between EM and CM patients. Results: A total of 47 Thai patients were enrolled (median [IQR] age 37.2 [28.6–50.4] years; 85.1%F, 44.7% EM; 70.2% galcanezumab). There was no difference in baseline characteristics and migraine disability assessment (MIDAS) between EM and CM. The overall ≥ 30%, ≥ 50%, and ≥ 70% monthly migraine day reduction rates at 6 months were 89.0%, 71.6%, and 58.5% with higher responders in EM. There was a significant decrease in monthly headache days (MHDs) over time (adjusted β = -0.42, p < 0.001) and a significant decrease in MIDAS score over time after the initiation of CGRP mAbs (adjusted β = -1.12, p = 0.003). However, there were no differences between the two diagnoses. There was no significant decrease in the number of abortive medication pills used over time after the initiation of CGRP mAbs. CM had a significantly steeper trend compared to those with EM. Conclusion: The first real-world study in Thailand demonstrated that CGRP mAbs therapy had efficacy for migraine treatment, as evidenced by a reduction in MHDs, decreased disability, and reduced use of abortive medications. Additionally, the response pattern to CGRP mAbs therapy was similar between EM and CM in terms of MHDs reduction and MIDAS score improvement.
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Efficacy of lasmiditan, rimegepant and ubrogepant for acute treatment of migraine in triptan insufficient responders: systematic review and network meta-analysis
(2024-12-01)
Laohapiboolrattana, Wattakorn
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Jansem, Priabprat
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Anukoolwittaya, Prakit
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Roongpiboonsopit, Duangnapa
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Hiransuthikul, Akarin
Background: Novel abortive treatments for migraine, ditans and gepants, have promising implications in triptan-insufficient responders with minimal existing comparative data. Our study aims to synthesize evidence through a systematic review and network meta-analysis to assess the comparative efficacy of lasmiditan, rimegepant and ubrogepant in triptan-insufficient responders. Method: We searched PubMed, Embase, CENTRAL, and EBSCO Open Dissertations up to May 2024. We included randomized controlled trials (RCTs) that compared novel abortive treatments, including lasmiditan, rimegepant, and ubrogepant, in migraine patients who self-reported insufficient response to triptans. Outcomes are represented using relative risks with corresponding 95% confidence intervals (CI). The surface under the cumulative ranking curve (SUCRA) was used to rank each medication. Results: A total of five phase 3 RCTs involving 3,004 patients were included in the analysis. All three agents were significantly superior to placebo for two-hour pain freedom (RR = 1.93, 95% CI [1.52, 2.46]), freedom from the most bothersome symptoms at two hours (RR = 1.55, 95% CI [1.37, 1.75]), and pain relief at two hours (RR = 1.46, 95% CI [1.35, 1.58]). No statistically significant differences in efficacy outcomes were observed among the three agents. However, lasmiditan 200 mg had the highest cumulative probability for two-hour pain freedom and relief (SUCRA 0.9, 0.8, respective), while rimegepant led in relieving the most bothersome symptoms (SUCRA 0.7). Conclusion: Lasmiditan, rimegepant, and ubrogepant are effective for acute treatment of migraine in triptan-insufficient responders, with high-dose lasmiditan showing the highest efficacy for pain control.
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A SUNCT-like headache associated with lateral pontine infarction – case series and systematic review
(2024-09-01)
Jansem, Priabprat
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Watanapa, Nattapat
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Thanprasertsuk, Sekh
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Rattanawong, Wanakorn
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Pongpitakmetha, Thanakit
Background and Aim: Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and autonomic symptoms (SUNA) are trigeminal autonomic cephalalgias (TACs). The study explores the potential association between SUNCT/SUNA-like headaches and lateral pontine infarctions. Methods: Case series and systematic review. Results: We present three cases diagnosed with SUNCT following lateral pontine infarction on magnetic resonance imaging (MRI), along with a review of these cases and 10 others from the literature. Discussion and Conclusion: This review suggests a connection between SUNCT/SUNA-like symptoms and lateral pontine infarctions. The section also delves into the anatomy and pathophysiology of these symptoms, proposing a mechanism involving neural pathway remodelling in the lateral brainstem.

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