SUNCT and SUNA: Recognition and Treatment

Abstract

The problem of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) management remains unsolved. Despite a myriad of therapeutic trials, no convincingly effective remedy for SUNCT and SUNA is available at present. Based on open-label communications, some patients seemed to benefit from some pharmacologic, interventional, or invasive procedures. Possible effective preventive drugs are carbamazepine, lamotrigine, gabapentin, and topiramate. At present, the drug of choice for SUNCT seems to be lamotrigine whereas SUNA may better respond to gabapentin. There is no available abortive treatment for the individual attacks. During the worst periods, intravenous lidocaine may decrease the flow of SUNCT/SUNA attacks. In SUNCT, bilateral blockade of the greater occipital nerve, and superior cervical ganglion opioid blockade have been reported as temporary/partially effective in one patient each. Botulinum toxin injected around the symptomatic orbit provided sustained relief to one patient. Owing to the scarcity of reports the results of these interventions should be taken as preliminary. Invasive therapy with interventions directed to the first division of the trigeminal nerve or Gasserian ganglion, with local anesthetics or alcohol, radiofrequency thermocoagulation, microvascular decompression, and gamma-knife neurosurgery, have been tried in the treatment of refractory SUNCT. Some patients seemed to benefit from such interventions, but one should still have a critical attitude to these claims since no convincing results have been obtained as yet. The few SUNCT patients who underwent deep brain hypothalamic stimulation obtained a substantial and persistent relief.

Tic, Triggering, and Tearing: From CTN to SUNHA

“…SUNCT is considered a moderate to severe pain syndrome, and SUNA may be slightly less severe . It is rarely pulsatile, but rather is usually burning, stabbing, and sometimes electric . Nevertheless, Cohen et al reported that 84% of their 43 SUNCT patients rated their pain as 10 of 10 on an 11 point visual analog scale (VAS) scale, and 66% of SUNA patients rated their pain as either VAS 9 or 10 .…”

“…In CTN, individual attacks have rapid onset and peak, and then subside, lasting overall from 10 seconds up to 2 minutes . In SUNHA, attacks also begin rapidly and end abruptly . A SUNHA attack lasts from 1 to 600 seconds, with a mean duration of about 1 minute, but longer lasting attacks of even 2‐3 hours have been reported .…”

“…The “sawtooth‐like” pattern consists of consecutive spike‐like paroxysms without reaching a pain‐free baseline. A mixture of short attacks on top of the typical plateau pattern termed “plateau‐like plus exacerbations” has also been described . The recognition of the varying pain patterns in SUNHA is significant, as the short attacks of pain could be mistaken for CTN and the longer‐duration patterns of stab groups and sawtooth could be mistaken for CTN with background pain, CH, or paroxysmal hemicranias (PH) …”

“…Triggering is not part of the ICHD‐3 diagnostic criteria of SUNHA patients but is noted in the comments, and therefore cases presenting with triggering, in particular in V2 or V3 distribution will be most likely diagnosed as CTN. Interestingly, triggers in SUNCT/SUNA may not be responsive to local anesthetic blocks . Extra‐trigeminal triggers that precipitate pain attacks have also been reported in SUNHAs and include neck movements …”

Cluster Headache

“…Patients with SUNA may respond better to gabapentin. 117 There has been a host of reports of diverse therapies for all of the cluster variant syndromes. These treatments include tricyclic antidepressants, botulinum toxin, surgical interventions as used for cluster headaches, intravenous corticosteroids, various AEDs, intravenous lidocaine, and celecoxib.…”