Objectives:
This study aimed to report the clinical profiles of patients with short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)/short-lasting ...unilateral neuralgiform headache attacks with cranial autonomic (SUNA) in a Japanese population by surveying those enrolled at a regional headache center in Japan.
Methods:
In this consecutive case series study, the clinical characteristics of patients with SUNCT (eight men, three women; mean age: 59.5 ± 20.5 years) and SUNA (five men, four women; mean age: 51.3 ± 18.4 years) who visited Tominaga Hospital from February 2011 to January 2017 were examined. Headaches were diagnosed according to the International Classification of Headache Disorders, Third edition (ICHD-3) guidelines.
Results:
Brief clusters of separate attacks were reported by all patients. The mean duration of attacks was 91.9 ± 87.9 s. Ipsilateral rhinorrhea was observed in 9 of 20 (45.0%) cases and facial sweating was observed in 1 of 20 (5.0%) cases. An eminent response to lamotrigine was observed in 9 of 9 (100%) patients; however, adverse events were only reported in 2 of 9 (22.2%) cases. An intravenous infusion of lidocaine was demonstrated to be completely successful for short-term prevention in 5 of 6 (83.3%) SUNCT cases.
Conclusions:
Lamotrigine can successfully treat most patients, and intravenous lidocaine is useful for the short-term preventive therapy of severe recalcitrant attacks in Japanese patients with SUNCT/SUNA.
Medical management of short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) syndrome and short-lasting unilateral neuralgiform headache attacks with cranial ...autonomic symptoms (SUNA) is often unsatisfactory.
The authors report nine cases of SUNCT/SUNA that failed medical treatment and had an aberrant arterial loop either in contact with or compressing the appropriate trigeminal nerve demonstrated on MRI. All underwent microvascular decompression of the ipsilateral trigeminal nerve for intractable pain.
Immediate and complete relief of SUNCT and SUNA symptoms occurred in 6/9 (67%) cases. This was sustained for a follow-up period of 9-32 months (mean 22.2). In 3/9 (33%) cases, there was no benefit. Ipsilateral hearing loss was observed in one case.
Medically intractable SUNCT and SUNA subjects with a demonstrable aberrant arterial loop impinging on the trigeminal nerve on neuroimaging may benefit from microvascular decompression.
The article presents diagnostic criteria, comparative characteristics of short-lasting unilateral neuralgiform headache attacks, including short-term unilateral neuralgic headaches with conjunctival ...injection and lacrimation (SUNCT) and short-term unilateral neuralgic headaches with cranial autonomic symptoms (SUNA), differential diagnosis with trigeminal neuralgia.
Trigeminal autonomic cephalalgias include cluster headache, paroxysmal hemicrania, and short‐lasting unilateral neuralgiform headache attacks with conjunctival injection, tearing, and rhinorrhea ...(SUNCT). Conventional pharmacological therapy can be successful in the majority of trigeminal autonomic cephalalgias patients.
Most cluster headache attacks respond to 100% oxygen inhalation, or 6 mg subcutaneous sumatriptan. Nasal spray of sumatriptan (20 mg) or zolmitriptan (5 mg) are recommended as second choice. The bouts can be brought under control by a short course of corticosteroids (oral prednisone: 60‐100 mg/day, or intravenous methylprednisolone: 250‐500 mg/day, for 5 days, followed by tapering off the dosage), or by long‐term prophylaxis with verapamil (at least 240 mg/day). Alternative long‐term preventive medications include lithium carbonate (800‐1600 mg/day), methylergonovine (0.4‐1.2 mg/day), and topiramate (100‐200 mg/day).
As a rule, paroxysmal hemicrania responds to preventive treatment with indomethacin (75‐150 mg/day).
A short course of intravenous lidocaine (1‐4 mg/kg/hour) can reduce the flow of attacks during exacerbations of SUNCT. Lamotrigine (100‐300 mg/day) is the preventive drug of choice for SUNCT. Gabapentin (800‐2700 mg/day), topiramate (50‐300 mg/day), and carbamazepine (200‐1600 mg/day) may be of help.
The trigeminal autonomic cephalalgias (TACs) are a group of primary headache disorders that include cluster headache (CH), paroxysmal hemicrania (PH), and short-lasting unilateral neuralgiform ...headache attacks with conjunctival injection and tearing/cranial autonomic features (SUNCT/SUNA). Hemicrania continua (HC) is often included with this group, although the second edition of The International Classification of Headache Disorders did not link the entities. Trigeminal autonomic cephalalgias are generally characterized by relatively short-lasting attacks of severe pain and lateralized associated features including the pain, cranial autonomic symptoms, and where present, migrainous symptoms, such as photophobia. Paroxysmal hemicrania has intermediate duration and intermediate attack frequency. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing has the shortest attack duration and the highest attack frequency. Hemicrania continua has a continuous pain with exacerbations that can include cranial autonomic symptoms as part of the phenotype. The syndromes share much in their pathophysiology and investigation paths; however, their treatment is distinct, so that the accurate differentiation is important for optimal management.
Abstract Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms ...(SUNA) are considered to be rare primary headache disorders. The purpose of this study was to define the clinical features, response to prophylactic treatment and efficacy of lignocaine by subcutaneous infusion for periods of acute exacerbation requiring hospitalisation. Over a period of 6 years (March 2000–February 2006) all cases of SUNCT and SUNA in neurology clinics at the Gold Coast Hospital, Australia, were reviewed. International Headache Society diagnostic criteria were used. Clinical features and response to treatment were prospectively recorded using headache diaries and magnetic resonance imaging of the brain was carried out. Twenty-four subjects with SUNCT or SUNA were identified. The incidence of these conditions was 1.2/100,000 and the prevalence 6.6/100,000. An episodic disease course was evident in 14/24 (58%) cases, whereas 10/24 (42%) had a chronic course. An aberrant vessel in close association with the fifth cranial nerve was seen in 88% of cases. A good or excellent response to lamotrigine was seen in 11/19 (58%) and was more effective in the episodic group (100%). A subcutaneous infusion of lignocaine proved completely effective on 11/14 (78%) occasions. SUNCT and SUNA are not rare conditions. Characterisation into episodic and chronic disease course appears to be of prognostic and therapeutic importance. Lamotrigine is effective in the majority of cases and subcutaneous lignocaine is useful as acute treatment for severe recalcitrant attacks.
Background
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 types of trigeminal autonomic cephalalgias (TACs).
Objective
To describe a series of patients with SUNCT and SUNA including relationship to pituitary tumors.
Method
All patients diagnosed with SUNCT or SUNA in the Calgary Headache Assessment and Management Program were reviewed.
Results
Six patients (five SUNCTs and one SUNA) were identified. The pain was severe, sharp, showed fixed-laterality, involved mainly the orbito-fronto-temporal region and was associated with autonomic symptoms. Attack duration ranged from 3 to 300 seconds and frequency was 1–200 paroxysms/day. MRI showed ipsilateral pituitary adenomas to the pain in five out of five of the SUNCT patients. Patients with adenomas underwent surgery. Pathology included three prolactinomas, and one mixed adenoma and gangliocytoma. One patient has remained headache free for 4 years after surgery. One was pain free for a year, and then headaches returned with tumor recurrence. Another had major improvement, and two have not improved. Patients were generally refractory to medications.
Conclusion
All five of our patients with typical SUNCT had pituitary tumors, with headache ipsilateral to the pituitary tumors in all cases. Tumor removal provided major improvement in three out of five patients. Medical treatment was only partially effective.
Short-lasting unilateral neuralgiform headache (Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing (SUNCT)/Short-lasting Unilateral Neuralgiform headache ...attacks with Autonomic Symptoms) is a trigeminal autonomic cephalalgia with difficult treatment and its management is based on neuromodulator drugs and sometimes ablative procedures on the trigeminal nerve. A positive response to occipital anesthetic blocks and peripheral and deep neurostimulation has also been described. We present the case of a patient with criteria of left SUNCT and transient response to occipital anesthetic blocks, satisfactorily controlled with pulsed radiofrequency (PRF) of the occipital nerve. Upon examination, the patient had tenderness in the left greater occipital nerve (GON). Blockade was performed with anesthetic and corticosteroid, obtaining a highly positive but transient response. After several nerve blocks, the patient was referred to the Pain Unit where pulsed radiofrequency on the left GON was performed. After two sessions, more than 90% of reduction of pain was achieved, maintained for 12 months. There haven’t been found data in the literature on the use of GON PRF for the treatment of SUNCT, while there are descriptions for other types of cranial pain. The intention of our case is to make this procedure to be considered as an alternative for the treatment of this entity in patients who respond to anesthetic blocks.
Background Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) are characterized by attacks of moderate to severe stabbing pain, strictly ...unilateral, with periorbital or temporal distribution, associated with cranial autonomic symptoms, such as lacrimation and redness of the ipsilateral eye. Methods To obtain mechanistic insights into the pathogenesis of SUNCT syndrome, more than 800 cases treated in our institution during the last 7 years were retrospectively reviewed. Two patients showed typical autonomic symptoms of SUNCT. Results Magnetic resonance imaging suggested potential compression of the trigeminal nerve by the intracranial artery in these cases and complete remission was achieved by microvascular decompression. Conclusions Microvascular decompression provides an appropriate therapeutic choice if vascular compression of the trigeminal nerve is identified. From our 2 cases, we propose that, in some cases of SUNCT diagnosed previously, characteristic symptoms were induced by compression of the side surface of the first branch of the trigeminal nerve at the root exit zone by the intracranial artery.
Chronic daily headache is a major worldwide health problem that affects 3–5% of the population and results in substantial disability. Advances in the management of headache disorders have meant that ...a substantial proportion of patients can be effectively treated with medical treatments. However, a significant minority of these patients are intractable to conventional medical treatments. Occipital nerve stimulation (ONS) is emerging as a promising treatment for patients with medically intractable, highly disabling chronic headache disorders, including migraine, cluster headache and other less common headache syndromes. Open-label studies have suggested that this treatment modality is effective and recent controlled trial data are also encouraging. The procedure is performed using several technical variations that have been reviewed along with the complications, which are usually minor and tolerable. The mechanism of action is poorly understood, though recent data suggest that ONS could restore the balance within the impaired central pain system through slow neuromodulatory processes in the pain neuromatrix. While the available data are very encouraging, the ultimate confirmation of the utility of a new therapeutic modality should come from controlled trials before widespread use can be advocated; more controlled data are still needed to properly assess the role of ONS in the management of medically intractable headache disorders. Future studies also need to address the variables that are predictors of response, including clinical phenotypes, surgical techniques and stimulation parameters.
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