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Factors contributing to inaccurate migraine diagnosis: a prospective study at a tertiary hospital in Southern Thailand
(2026-12-01)
Suwanlaong, Kanokrat
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Sittisomwong, Sirianong
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Dutsadeethammo, Duangkamon
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Anukoolwittaya, Prakit
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Rattanawong, Wanakorn
Background: Migraine is a common and disabling neurological disorder, yet diagnostic accuracy remains suboptimal, especially in non-specialist settings. Misdiagnosis may lead to delayed treatment, medication overuse, and reduced quality of life. The objective of this study was to estimate the proportion of patients with migraine attending the headache clinic who were misdiagnosed or not diagnosed as having migraine before attending the headache clinic, and to identify factors associated with inaccurate migraine diagnosis among patients before attending a tertiary hospital in Southern Thailand. Methods: A prospective, cross-sectional study was conducted at Songkhla Hospital between July 2024 and April 2025. Adult patients (≥ 18 years) with a final migraine diagnosis confirmed by two blinded independent neurologists were enrolled. Participants were divided into two groups: (1) an appropriate diagnosis group, defined as patients who received a correct diagnosis of migraine at their initial consultation with any physicians prior to attending the headache clinic; and (2) an inappropriate diagnosis group, defined as patients who were previously misdiagnosed with another headache disorder or had not been diagnosed with migraine before their headache clinic visit. Data on demographics, clinical features, and the specialty of the first attending physician were analyzed using univariable and multivariable logistic regression. Results: 90 patients were included (87.8% female, mean age 43.4 ± 14.8 years). 43.3% had been misdiagnosed at their initial visit. The most common incorrect diagnoses were tension-type headache and sinusitis. Multivariable analysis identified five independent factors significantly associated with inappropriate diagnosis: male sex (adjusted OR 7.77, 95% CI 1.07–56.50, p = 0.043), bilateral headache (aOR 3.90, 95% CI 1.25–12.13, p = 0.019), lack of worsening by physical activity (aOR 5.09, 95% CI 1.54–16.89, p = 0.008), presence of vertigo/dizziness (aOR 4.39, 95% CI 1.22–15.83, p = 0.024) and initial consultation with a non-neurologist (aOR 7.92, 95% CI 2.63–23.88, p < 0.001),. Conclusion: Misdiagnosis of migraine remains frequent in clinical practice, particularly among patients initially evaluated by non-neurologists. Atypical symptom profiles—such as bilateral pain, lack of activity-related exacerbation, or associated vertigo—contribute to diagnostic inaccuracy. Enhanced awareness and targeted education for primary physicians are essential to improve diagnostic precision and reduce treatment delay.
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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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Teaching NeuroImage: An Unusual Cause of Deep Cerebral Venous Sinus Thrombosis
(2026-08-11)
Yolsiriwat, Chayanis
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Phuenpathom, Warongporn
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Hemachudha, Pasin
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Roongaraya, Pitchapa
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Songsiriritthigul, Weekit
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Diagnostic and prognostic value of blood neurofilament light chain in ischemic stroke: an individual patient data meta-analysis
(2026-06-01)
Barba, Lorenzo
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Romoli, Michele
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Benkert, Pascal
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Hofer, Lisa
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Maia, Luis F.
Background: We aimed to conduct an individual patient data meta-analysis on blood neurofilament light chain (NfL) in ischemic stroke (IS) to enhance its clinical applicability. Methods: We performed a systematic literature search of studies on blood NfL measured in adult patients within 30 days after IS onset and derived age- and BMI-adjusted Z-scores based on a previously published reference population of healthy controls. We collected clinical, radiological and biochemical parameters of IS patients and tested associations of NfL at defined timepoints after IS onset (D1: < 24 h; D2: 24–48 h; D3: 48–72 h; D4–5: 72–120 h; D6–7: 120–168 h; D8–30: > 168 h) with baseline characteristics and 3-month follow-up outcomes (modified Rankin Scale, mRS; survival). Results: We included 4081 blood NfL values from 2872 participants (IS n = 1985, transient ischemic attack n = 88, healthy controls n = 799) of 18 published studies and 3 unpublished cohorts. In patients with IS, NfL Z-score progressively increased from D1 [median: 2.0 (IQR: 0.9–2.9)] to D6–7 [median: 3.5 (IQR: 3.0–3.8)], with discriminative ability being high for IS vs. controls (AUC: 0.79–0.97) and fair for IS vs. TIA (AUC: 0.64–0.80). Higher NfL Z-score at D1 was associated with greater risk of symptomatic intracranial hemorrhage (aOR = 1.33, p = 0.014) and, from D2 onwards, with larger infarct lesion volume (highest Spearman’s rho: 0.795 at D6-7). NfL independently predicted a mRS > 2 (aOR = 1.31, p < 0.001) and mortality (aOR = 1.67, p < 0.001) at 3 months. Conclusions: Blood NfL level was progressively elevated after IS, could discriminate IS from healthy controls with high accuracy and had prognostic value for intra-hospital complications and 3-month clinical outcomes in IS.
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Transcultural headache medicine: A framework for integrating cultural contexts into headache science and care – a call to action from the International Headache Society
(2026-04-01)
Peres, Mario F.P.
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Lucchetti, Giancarlo
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Vallada, Homero
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Riso, Ivy L.
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Westenhofen, Georgia K.
Headache disorders are among the most disabling neurological conditions, affecting over 1.5 billion people globally. Despite advances in pharmacological therapies, major inequities persist due to underdiagnosis, undertreatment and limited access to effective care, particularly in low- and middle-income countries. Social determinants of health, including cultural meanings, language and health beliefs, are increasingly recognized as key drivers of disparities in burden, diagnosis and treatment outcomes. Traditional medicine, used by more than 80% of the global population, remains first-line care in many regions and continues to influence therapeutic choices in high-income settings. Major systems such as Ayurveda, Traditional Chinese Medicine, Unani and Tibetan medicine, as well as diverse indigenous traditions, emphasize holistic approaches that integrate mental and physical symptoms into diagnosis and management. Additionally, religious and spiritual practices are commonly used to relieve suffering and pain. These culturally grounded explanatory models not only strongly shape health-seeking behavior, treatment adherence and patient narratives, but also may delay biomedical care when misconceptions or unsafe practices predominate. This paper introduces Transcultural Headache Medicine as an emerging framework that integrates cultural contexts, linguistic diversity and traditional practices into headache research, clinical care and policy. We review global traditions and therapeutic modalities including herbal, physical, mental and spiritual approaches, and propose a research agenda combining ethnography, culturally adapted diagnostic tools, experimental studies and clinical trials to evaluate benefits, risks, and contextual effects. We conclude with a call to action from the International Headache Society, aiming to map and evaluate culturally embedded practices, strengthen rigorous evidence and build a global learning network that supports culturally safe integration of effective, affordable and safe headache care.
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2025 Highlights in medication overuse and medication overuse headache
(2026-01-01)
Rattanawong, Wanakorn
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Iannone, Luigi Francesco
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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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