Fasting-induced headaches (FIHs) have been shown to occur on the first day of Ramadan and clearly decline thereafter. Despite the wealth of knowledge about different types of headaches (e.g., migraine-, cluster-, and tension-type headaches), research on the mechanism underlying FIHs, as well as their treatment, remains scarce. Our study aimed to investigate any association between FIHs during the first day of Ramadan and potential headache-related biomarkers, including fasting blood glucose (FBG), C-reactive protein (CRP), magnesium, vitamin B9, vitamin B12, homocysteine, and calcitonin gene related peptide (CGRP), and to assess whether a prophylactic use of paracetamol may influence these biomarkers. As part of a randomized, open-label clinical trial that evaluated the effect of paracetamol as a prophylactic therapy for FIH, blood samples from stratified subjects in the prophylaxis and control groups were withdrawn while fasting after the 1st dose of paracetamol (in the prophylaxis group) and prior to reporting headache occurrence. Plasma and serum were separated for 61 subjects; 31 and 30 subjects from the prophylaxis and control groups, respectively. Overall, no significant differences were found in the levels of FBG, CRP, magnesium, vitamin B9, and vitamin B12 in headache-suffering subjects compared to those without headache despite the use of paracetamol for prophylaxis. Homocysteine, however, was significantly reduced in all subjects who experienced FIH compared to those without headache (median 6.9 [1.6] vs. 7.7 [2.7] umol/L; p = 0.041). On the contrary, when the CGRP was measured using immunoassay, it was found to be significantly elevated in all headache-suffering subjects compared to those without headache (median 126.1 [17.7] vs. 105.8 [19.6] pg/mL; p ≤ 0.0001). This difference was maintained upon comparing the headache to non-headache subjects in both the prophylaxis (median 121.5 [15.4] vs. 105.8 [9.4] pg/mL; p < 0.01) and control groups (median 128.5 [28.3] vs. 105.8 [23.8] pg/mL; p < 0.01). Additionally, an elevated CGRP level was found to increase the odds of having a FIH [OR = 1.32; 95%CI 1.06–1.22]. Our findings revealed the role of CGRP in FIHs for the first time and suggest further investigation in signaling pathways downstream CGRP receptors. Furthermore, the modulation CGRP or CGRP receptors could have a clinical application in the prevention of FIHs. This study was registered with the Saudi Food and Drug Authority in the Saudi Clinical Trials Registry (SCTR; No. 22122102).

Objective: To establish expert consensus on the preventive treatment of migraine in Saudi Arabia, with a focus on the use of calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs), in light of the latest international guidelines and local clinical practice. Method: A record-based study was performed retrospectively in Radiology department at our Hospital in Eastern region of Saudi Arabia, from Jan. 2019-2024. Adult patients for whom MRI brains were conducted for epilepsy work-up with added SWAN (susceptibility weighted angiography) sasequence were considered. Brain tumor, post-injury, and post-surgery cases were excluded. A venous angioma was documented when a tuft of veins drained to a larger vein (traversing through cortex or reaching under ependymal layer), appeared low signal curvilinear brnaching structure on SWAN image. The usefulness of the SWAN sequence in the detection of venous malformation determined if the visualized abnormality was found to be related to a focus resulting in abnormal waves on the brain electroencephalography. This observation was compared to the accidently found such malformations that were seen in epileptic patients with normal EEGs (control group). Fisher’s Exact test was applied and a p-value of <0.05 was taken as statistically significant for an association. Results: The expert panel reviewed updated clinical data and recent international guidelines recommending CGRP mAbs as first-line preventive treatment options. The panel reached consensus on key aspects of migraine management in Saudi Arabia, including treatment initiation criteria, patient selection, and the role of CGRP mAbs in clinical practice. The recommendations emphasize the need for earlier initiation of effective treatments to reduce disease burden and improve quality of life. Conclusion: This expert consensus provides updated guidance on the preventive treatment of migraine in Saudi Arabia, supporting the integration of CGRP mAbs as a first-line option. These recommendations aim to enhance the standard of migraine care and address unmet needs in the local healthcare setting.

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.

Objective: To delineate the trend of use of botulinum toxin, including onabotulinum toxinA (OTA), in active military personnel and veterans with the diagnoses of migraine and post-traumatic headache (PTH) and describe the efficacy of botulinum toxin administration. Background: Service members and veterans represent a unique population in the medical management of headache disorders, particularly migraine. They exhibit higher susceptibility to pain of greater intensity and longer durations, possibly due to their history of exposure to combat, trauma, and the associated psychological stresses. Given the burden and morbid nature of these headache disorders, prophylactic measures to reduce migraine attacks and disability are imperative. Specifically, the use of OTA for migraine prophylaxis has been well validated in chronic migraine. Methods: The scoping review conformed to guidelines delineated by Preferred Reporting Items for Systematic Reviews and Meta- Analysis (PRISMA). The databases Medline, Embase, and Google Scholar were accessed for our literature search, and the time frame of the search was set from database inception to April 1, 2024. Results: A total of 8 articles meeting the inclusion criteria were obtained after screening a total of 43 papers. Studies were primarily conducted in the United States (87.5%), with a single article published on veterans from Taiwan. Study types were mainly retrospective chart reviews with the exception of 2 randomized controlled trials. Chronic migraine was the most common headache diagnosis examined, being assessed in 6 studies, followed by PTH, which was represented in the remaining 2 studies. Conclusion: The occupational exposure of service members appears to result in a higher incidence of headache disorders such as chronic migraine and PTH, which are amenable to preventative management such as that with botulinum toxin. Despite its effectiveness, the use of botulinum toxin in treating headaches and craniofacial pain in service members remains under-researched, warranting further exploration in this population, specifically.