A case of short–lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Discussion of clinical features and differential diagnosis

Abstract

Chronic short-lasting headaches, in which trigeminal autonomic cephalalgias (TACs) are included, are relatively rare syndromes and not always well recognised. We present a case highly suggestive of short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) and we try to affirm essential points to distinguish the diagnosis from other TACs and chronic short-lasting headaches. We conclude that the qualifying points for differential diagnosis are number and duration of attacks in a day, presence of autonomic features and lack of indomethacin effect. Keywords SUNCT • TACs Case reportA 47-year-old man was admitted to our Headache Centre for unilateral attacks of severe orbital headache, sometimes with temporal stabbing, extremely frequent (30-50 episodes in a day), lasting 15-30 s, associated with evident conjunctival injection and lacrimation, nasal congestion, rhinorrhoea and eyelid oedema. The pain quality was described as burning and throbbing. He was totally pain-free between attacks.NMR of brain did not showed any pathologic condition. The patient had presented this clinical condition for two weeks before arriving and he had experienced similar symptoms 1 and 4 years before, for about one month each time. In both events the clinical picture remitted spontaneously, and on these occasions the symptoms did not respond to therapy with subcutaneous sumatriptan, or to indomethacin.No trigger zones were documented. Sometimes neck movements elicited the attacks.The diagnosis we made was a short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) case, with respect to diagnostic criteria of the revised IHS classification. Particularly, we think that the attacks' duration and frequency, the important autonomic concomitant features and the lack of indomethacin effect represented the qualifying points for diagnosis. DiscussionSUNCT is one of the rarest trigeminal autonomic cephalalgias (TACs) and it shows a dramatic picture for the number of crises that create a condition of important disability. The worst characteristic is not the intensity of the crises, described as medium or severe, but never extremely severe like other chronic paroxystic cephalalgias, but the number of them and the intense autonomic involvement of the involved eye.The syndrome was described first in 1978 [1] and afterwards characterised [2] for the extreme shortness of crises that last only a few seconds and the total absence of symptoms in the intercritical periods. The most intensive pain occurs in the orbital and peri-orbital regions and can irradiate ipsilaterally in the frontal, temporal and nasal zones, and to cheek and palate. The quality of pain is described as burning, stabbing or throbbing, and more rarely as an electric current. Paroxysms start and finish acutely, reaching the highest level in 2.3 s. Single cases described the pain for longer times also, but the revised criteria of the International Headache Society indicate a duration between 10 and 120 s for ...

Botulinum Toxin A for the Treatment of a Child with SUNCT Syndrome

“…The second edition of the International Headache Society classification [ 2 ] defines the pain onset as occurring within 5–240 s, with 3–200 attacks per day, but the recently revised 2013 edition states that onset may occur over 1 s to 10 minutes and that there may be two or more attacks per day [ 10 ]. In contrast with trigeminal neuralgia, SUNCT has no refractory period [ 11 ]. The pain of SUNCT is accompanied by conjunctival injection, tearing, and other autonomic nerve signs.…”