In Japan, monoclonal antibodies blocking the calcitonin gene-related peptide (CGRP) pathway was introduced for the prevention of episodic and chronic migraine in April 2021. We describe real-world experience of galcanezumab, erenumab, and fremanezumab in patients with migraine in our headache clinic. We treated 576 patients with migraine from April 2021 to June 2022. After 6 months or more of treatment, 63.0％ (GL) , 59.8％ (ER) , and 59.6％ (FR) of the patients in each group achieved >50％ reduction in monthly migraine days (MMD) . A total of 61 patients (27, 22, and 12 patients treated with GL, ER, FR, respectively) stopped the use of their respective monoclonal antibodies because of significant reduction in MMD and improvement of quality of life. However, 22 of these 61 patients needed to resume the injection after a mean of 8.02 months. The characteristics of patients who stopped the monoclonal antibodies with satisfactory improvements were episodic migraine, female, shorter duration of migraine history, and less prior use of preventive medicines.
  Although our experience is limited, this study demonstrated that treatment with CGRP-related antibodies is effective and safe for the prevention of migraine in Japanese patient population.

  Pediatric headache is considered one of the most underdiagnosed conditions. We investigated pediatric headache patients who first visited the Department of General Pediatrics at Nagano Children’s Hospital, a tertiary pediatric facility. Over a period of about 11 years, 115 patients visited the department with headache as the main complaint. There was no difference in numbers between male and female patients. Primary headaches accounted for 39％ and secondary headaches for 61％. Migraine accounted for 76％ of primary headaches. Secondary headaches were often psychogenic, orthostatic dysregulation, and transient such as infection. Orthostatic dysregulation was seen primarily in adolescent patients, while transient headache was more common in younger patients. Family history of headache was present in 82.9％ of primary headaches and 73.5％ of secondary headaches. Considering the high rate of family history, it can be concluded that a family history of headache could encourage a patient’s family to bring their children to a medical facility. In addition, because a family history of headache is also common in secondary headache, it is important to obtain a detailed medical history and to understand the unique pathophysiology of the condition in children in order to diagnose pediatric headaches.

  【Introduction】In recent years, the number of foreign patients visiting medical clinics in depopulated areas as well as in urban areas has been increasing in Japan. This can be attributed to factors such as the increased acceptance of foreign technical trainees to compensate for the labor shortage, as well as a rise in foreign tourists visiting Japan. On the other hand, the information obtained through medical interviews is crucial for the diagnosis and treatment of diseases. In response to this situation, the Ministry of Health, Labour and Welfare created a manual for medical institutions. And medical institutions nationwide have been working to improve their system for accepting foreign patients. In fact, the Ministry has published multilingual explanatory materials for foreigners on its website. However, there are limitations. For example, in the headache questionnaire, it does not include crucial information for differentiating headache classifications, such as the location, characteristics, impact on daily life, prodromes or auras. With the aim of addressing these limitations, we proposed the creation of a multilingual headache questionnaire using the translation function of generative AI and discussed the possible features and challenges.
   【Materials and Method】We examined the trends in the resident foreign population in our region and the foreign patients at our hospital from 2015 to 2022. We utilized a generative AI to translate the headache questionnaire that our department had previously created. The 10 selected languages for translation were based on the nationalities of foreign patients who frequently visited our hospital.
  【Results】 The trends of the resident foreign population and the foreign patients showed an increase from around 2015 and continued to rise until the COVID-19 pandemic in 2020, with a strong correlation between the two. The nationalities of foreign patients spanned 40 countries over the entire period, highlighting the diversity and multilingual nature of the patient population. We edited the questionnaire by listing the translated results and the original Japanese for each question item. As a result, it became possible to understand the results of the medical interview even if the foreign patient’s language was completely incomprehensible.
   【Discussion】This approach can accommodate all languages, including rare ones, and proves valuable for native languages. It allows for a more precise assessment of the interview content, increasing its uniqueness. It can also be applied to various other questionnaires, such as headache diaries, making it highly versatile. It can quickly adapt to unexpected visits, and is efficient. AI-generated translation has been noted that human oversight is necessary due to issues such as literal translation errors, cultural nuances being missed and mistranslation of specialized terminology. However, since the language used in medical questionnaires is at a conversational level, it is believed that significant issues can be avoided.
  【Conclusion】 This approach is expected to enhance diagnostic efficiency and reduce the risk of information gaps or shortages among foreign patients, which is expected to be increasingly valuable in the diagnosis and treatment of foreign patients.

  In cases of familial hemiplegic migraine or epilepsy, cerebral atrophy may occur at the site of focal symptoms. We report a case of sporadic hemiplegic migraine with marked cerebral atrophy 5 years after the initial diagnosis. The patient was a man in his 50s. The patient had a history of migraine with aura. He was hospitalized three times in two years for migraines with focal symptoms such as aphasia, dyslexia, and visual field disturbances. On his first episode, he was diagnosed as transient ischemic attack and started taking Cilostazol, which seemed inappropriate retrospectively. On his second episode, he showed general convulsion and started taking an antiseizure medication. On his third episode, he was diagnosed with hemiplegic migraine with left hemiplegia and started taking other antiseizure medications with known preventive effects on migraine. Cerebral perfusion study showed hypoperfusion at the focus of cortical spreading depression during the first episode, whereas hyper-perfusion during the second and the third episode. Brain imaging 5 years after the first visit revealed marked brain atrophy on his right occipital lobe. He passed away when he drowned due to epileptic seizure while bathing. As the mechanism of the focal brain atrophy, neuronal damage due to (1) drastic changes in cerebral perfusion that appears during aura, (2) repetitive cortical spreading depression, and (3) coexistence of epilepsy, were suggested. The neuronal damage which we observed as FLAIR high lesion at the focus of cortical spreading depression is also described as cortical cytotoxic edema or cortical laminar necrosis. Regarding the possibly poor outcome of those hemiplegic migraine patients, recently approved promising agents such as anti-calcitonin-gene related peptide (CGRP) -related monoclonal antibodies or lasmiditan should have been considered.