SUNCT and SUNA: medical and surgical treatments

Abstract

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) are rare and often disabling primary headache disorders. Their management can be challenging. The abortive therapies are not generally useful as the attacks are relatively short lasting. A myriad of pharmacological preventive treatments have been tried in single case reports or small series in an openlabel fashion. Lamotrigine, as an oral preventive treatment, and lidocaine, as an intravenous transitional treatment, seem to be the most effective therapies. For medically intractable chronic forms of SUNCT and SUNA, several surgical approaches have been tried. These include ablative procedures involving the trigeminal nerve or the Gasserian ganglion, microvascular decompression of the trigeminal nerve, and neurostimulation techniques. This review provides an overview of the current pharmacological and surgical options for SUNCT and SUNA syndromes.

Tic, Triggering, and Tearing: From CTN to SUNHA

“…It is thus probable that V2 and V3 SUNCT/SUNA are under reported. Recently, Lambru and Matharu suggested that when SUNHA occurs in the maxillary and mandibular dermatomes, tearing and conjunctival injection may be rare or absent . With this in mind, it is possible that SUNHA patients with little tearing or conjunctival injection are often diagnosed as CTN.…”

“…Examining individual patients, 11 had significantly prolonged attacks but no CAS. Under current thinking, these patients would likely not be diagnosed as SUNA or SUNCT, and their presentation supports the proposition that longer attack durations are indeed part of the CTN spectrum . Moreover, within this last group of patients, eight of them demonstrated an identifiable trigger area and refractory period in the presence of paroxysms lasting significantly longer than 2 minutes …”

Peripheral nerve blocks in the treatment of short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) during pregnancy

“…Recent studies have reported satisfactory results using antiepileptic drugs; currently, the first-line agent is lamotrigine, whereas the second-line drugs include gabapentin and topiramate. [4,5] For severe and treatment-resistant patients, there are pioneer studies on deep brain stimulation and microvascular surgery. [6][7][8][9] Some authors have reported conflicting results regarding the efficacy of great occipital nerve (GON) block.…”

SUN: Short‐Lasting Unilateral Neuralgiform Headache Attacks

“…Topiramate is a useful preventive medication for a number of headache syndromes, including migraine, CH, PH, and SUN. It has been found to be beneficial in open label studies for SUN in 11/22 patients and in another study in 24/54 patients . One double‐blinded placebo controlled study found a beneficial effect in 2/5 patients .…”

“…A short course of corticosteroids is often used in CH in order to abolish a bout of episodic CH (ECH), or to afford a few weeks of pain relief in chronic CH (CCH) while a preventive medication is introduced. This has been applied in SUNCT, with variable results . Intravenous methylprednisolone less than 1 mg/kg/day has been beneficial in three patients with episodic SUNCT …”