SUNCT syndrome responsive to gabapentin (Neurontin)

Cigarette smoking history (personal and secondary childhood exposure) in non-cluster headache trigeminal autonomic cephalalgias: A clinic based study

OBJECTIVE

To look at cigarette smoking history (personal and secondary exposure as a child) in non-cluster headache trigeminal autonomic cephalalgias seen at a headache clinic and to determine smoking exposure prevalence utilizing previously published data.

METHODS

Retrospective chart review and PubMed/Google Scholar search.

RESULTS

Forty-eight clinic patients met ICHD-3 criteria for non-cluster headache trigeminal autonomic cephalalgias. Four had paroxysmal hemicrania, 75% were smokers and secondary exposure was noted in all. 16 patients had short lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) or short lasting unilateral neuralgiform headache attacks with autonomic symptoms (SUNA), 12.5% were smokers and secondary exposure was noted in 91%. Twenty-eight patients had hemicrania continua, 21% were smokers and secondary exposure was found in 62.5%.Since 1974 there have been 88 paroxysmal hemicrania, 50 SUNCT or SUNA and 89 hemicrania continua patients with a documented smoking exposure history. From current data and previous studies, a smoking history was noted in 60% paroxysmal hemicrania, 18% SUNCT and SUNA and 21% hemicrania continua patients.

CONCLUSION

A cigarette smoking history appears to be connected to paroxysmal hemicrania (personal and secondary exposure) and possibly to SUNCT/SUNA (secondary) and hemicrania continua (secondary).

[Trigeminal autonomic cephalgias: features of diagnosis and treatment]

Trigeminal autonomic cephalgias is a group of primary headaches, including cluster headache, paroxysmal hemicrania and hemicrania continua, as well as two forms of short- lasting unilateral neuralgiform headache attacks, the complexity of diagnosis of which is determined by the low prevalence and some similarity of clinical manifestations both among themselves and with other diseases in particular with migraine and trigeminal neuralgia. Despite the rather short duration of headache attacks, the intensity of the pain syndrome reaches a severe and very severe degree, and the high frequency of paroxysms per day significantly complicates abortion treatment and leads to a pronounced professional and social maladjustment. At the same time, the possibility of using effective specific prophylactic therapy determines the importance of accurate diagnosis and, therefore, the knowledge of neurologists on this issue.

Short-Lasting Unilateral Neuralgiform Headache Attacks

Short-lasting unilateral neuralgiform headache attacks (SUNHA) is characterized by strictly unilateral trigeminal distribution pain that occurs in association with ipsilateral cranial autonomic features. There are two subtypes: short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA). These disorders are rare but highly disabling. The management of SUNHA can be challenging. The abortive therapies are not generally useful as the attacks are relatively short-lasting. A myriad of pharmacological preventive treatments has been tried in single case reports or small series in an open-label fashion. Lamotrigine, as an oral preventive treatment, and lidocaine, as an intravenous transitional treatment, seems to be the most effective therapies. For medically intractable SUNHA, several surgical approaches have been tried. These include ablative procedures involving the trigeminal nerve or the Gasserian ganglion, microvascular decompression (MVD) of the trigeminal nerve, and neurostimulation techniques. MVD, occipital nerve stimulation, and ventral tegmental area deep brain stimulation have all been found to be effective in open-label series with relatively high-response rates. There is a considerable clinical, therapeutic, and radiological overlap between SUNCT, SUNA, and trigeminal neuralgia (TN). Despite being considered distinct conditions, the emerging evidence suggests a broader nosological concept of SUNCT, SUNA, and TN; these conditions may constitute a continuum of the same disorder, rather than separate clinical entities. Consideration needs to be given to classifying SUNHA with TN as a cranial neuralgia rather than as a trigeminal autonomic cephalalgia.

Therapeutical approaches to paroxysmal hemicrania, hemicrania continua and short lasting unilateral neuralgiform headache attacks: a critical appraisal

Background

Hemicrania continua (HC), paroxysmal hemicrania (PH) and short lasting neuralgiform headache attacks (SUNCT and SUNA) are rare syndromes with a difficult therapeutic approach. The aim of this review is to summarize all articles dealing with treatments for HC, PH, SUNCT and SUNA, comparing them in terms of effectiveness and safety.

Methods

A survey was performed using the pubmed database for documents published from the 1st January 1989 onwards. All types of articles were considered, those ones dealing with symptomatic cases and non-English written ones were excluded.

Results

Indomethacin is the best treatment both for HC and PH. For the acute treatment of HC, piroxicam and celecoxib have shown good results, whilst for the prolonged treatment celecoxib, topiramate and gabapentin are good options besides indomethacin. For PH the best drug besides indomethacin is piroxicam, both for acute and prolonged treatment. For SUNCT and SUNA the most effective treatments are intravenous or subcutaneous lidocaine for the acute treatment of active phases and lamotrigine for the their prevention. Other effective therapeutic options are intravenous steroids for acute treatment and topiramate for prolonged treatment. Non-pharmacological techniques have shown good results in SUNCT and SUNA but, since they have been tried on a small number of patients, the reliability of their efficacy is poor and their safety profile mostly unknown.

Conclusions

Besides a great number of treatments tried, HC, PH, SUNCT and SUNA management remains difficult, according with their unknown pathogenesis and their rarity, which strongly limits the studies upon these conditions. Further studies are needed to better define the treatment of choice for these conditions.

Electronic supplementary material

The online version of this article (doi:10.1186/s10194-017-0777-3) contains supplementary material, which is available to authorized users.

Short-Lasting Unilateral Neuralgiform Headache Attacks with Conjunctival Injection and Tearing

SUNCT (Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing) and SUNA (Short-lasting Unilateral Neuralgiform headache attacks with cranial Autonomic symptoms) are rare primary headache syndromes, classified as Trigeminal Autonomic Cephalalgias (TACs). Hypothalamic involvement in the TACs has been suggested by functional imaging data and clinically with deep brain stimulation.

Fifty-two patients (43 SUNCT, 9 SUNA) were studied to determine the clinical phenotype of these conditions and response to medications. A functional imaging study explored activation of the posterior hypothalamus in attacks of SUNCT/SUNA.

The clinical study characterised SUNCT and SUNA in terms of epidemiology, phenotype and clinical characteristics.

Indomethacin is ineffective on single-blind testing. Intravenous lidocaine was effective in all cases. Open-label trails showed the effectiveness of lamotrigine, topiramate and gabapentin.

On functional imaging there was hypothalamic activation bilaterally in 5/9 SUNCT patients, and contralaterally in two patients. Two SUNCT patients had ipsilateral negative activation. In SUNA the activation was bilaterally negative. There was no hypothalamic activation in a patient with SUNCT secondary to a brainstem lesion.

The data suggests that there should be revised classification for SUNCT and SUNA, with an increased range of attack duration and frequency, cutaneous triggering of attacks, and a lack of refractory period. The concept of ‘attack load’ is introduced. The lack of response to indomethacin and the response to intravenous lidocaine, are useful in diagnostic and therapeutic terms, respectively. Preventive treatments include lamotrigine, gabapentin and topiramate. The role of hypothalamic involvement in SUNCT and SUNA as TACs is considered.

SUNCT Syndrome Responsive to Intravenous Lidocaine

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) is a primary headache syndrome that has been reported to be resistant to treatment with intravenous lidocaine. We report four cases of SUNCT in whom intravenous lidocaine (1.3-3.3 mg kg−1 h−1) completely suppressed the headaches for the duration of the infusion. The headache returned after cessation of treatment. Two patients went on to have their symptoms controlled on topiramate (50-300 mg daily). One patient had typical migrainous aura in association with some of the attacks of pain but never migrainous headaches. These cases suggest that treatment with lidocaine can be considered when acute intervention is required to suppress a severe exacerbation of SUNCT, and further broaden the therapeutic and clinical background of this syndrome.

Pain Part 9: Trigeminal Autonomic Cephalalgias

The trigeminal autonomic cephalalgias are a group of rare, highly disabling, primary headache syndromes distinctly characterized by the unilaterality of their attacks and presence of cranial autonomic symptoms. Although pain is often localized to the peri-orbital and temporal regions, it is not uncommon for pain to radiate to tooth-bearing areas and mimic toothache or jaw pain. Hence, dental practitioners should be aware of these syndromes to enable appropriate referral and avoid unnecessary, and often irreversible, dental treatments. Many dentists will not have heard of these conditions but must remain vigilant, and ensure that they are not confused with trigeminal neuralgia, so that their patients are appropriately advised and referred. Clinical relevance: The dental practitioners may be the first line of healthcare providers consulted by these patients in the hope of obtaining pain relief. Lack of familiarity with an uncommon condition may lead to poor patient management.

SUNCT/SUNA: A Review

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting neuralgiform headache attacks with cranial autonomic features (SUNA) are rare headache disorders characterized by severe, short-lasting headaches. These headache disorders are often refractory to treatment and can be secondary phenomena. This article reviews the history, pathophysiology, and treatment of these disorders. Both pharmacotherapy and procedural interventions are discussed in context of historical and more recent reports.

The Neuropharmacology of Cluster Headache and other Trigeminal Autonomic Cephalalgias

Trigeminal autonomic cephalalgias (TACs) are a group of primary headaches including cluster headache (CH), paroxysmal hemicrania (PH) and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Another form, hemicrania continua (HC), is also included this group due to its clinical and pathophysiological similarities. CH is the most common of these syndromes, the others being infrequent in the general population. The pathophysiology of the TACs has been partly elucidated by a number of recent neuroimaging studies, which implicate brain regions associated with nociception (pain matrix). In addition, the hypothalamic activation observed in the course of TAC attacks and the observed efficacy of hypothalamic neurostimulation in CH patients suggest that the hypothalamus is another key structure. Hypothalamic activation may indeed be involved in attack initiation, but it may also lead to a condition of central facilitation underlying the recurrence of pain episodes. The TACs share many pathophysiological features, but are characterised by differences in attack duration and frequency, and to some extent treatment response. Although alternative strategies for the TACs, especially CH, are now emerging (such as neurostimulation techniques), this review focuses on the available pharmacological treatments complying with the most recent guidelines. We discuss the clinical efficacy and tolerability of the currently used drugs. Due to the low frequency of most TACs, few randomised controlled trials have been conducted. The therapies of choice in CH continue to be the triptans and oxygen for acute treatment, and verapamil and lithium for prevention, but promising results have recently been obtained with novel modes of administration of the triptans and other agents, and several other treatments are currently under study. Indomethacin is extremely effective in PH and HC, while antiepileptic drugs (especially lamotrigine) appear to be increasingly useful in SUNCT. We highlight the need for appropriate studies investigating treatments for these rare, but lifelong and disabling conditions.

SUNCT and SUNA: medical and surgical treatments

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 open-label 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.

SUNCT/SUNA and neurovascular compression: new cases and critical literature review

BACKGROUND

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache with cranial autonomic symptoms (SUNA) are primary headache syndromes. A growing body of literature has focused on brain magnetic resonance imaging (MRI) evidence of neurovascular compression in these syndromes.

OBJECTIVE

The objective of this article is to assess whether SUNCT is a subset of SUNA or whether the two are separate syndromes and clarify the role of neurovascular compression.

METHOD

We describe three new SUNCT cases with MRI findings of neurovascular compression and critically review published SUNCT/SUNA cases.

RESULTS

We identified 222 published SUNCT/SUNA cases. Our three patients with neurovascular compression added to the 34 cases previously described (16.9%). SUNCT and SUNA share the same clinical features and therapeutic options. At present, there is no available abortive treatment for attacks. Lamotrigine was effective in 64% of patients; topiramate and gabapentin in about one-third of cases. Of the 34 cases with neurovascular compression, seven responded to drug therapies, 16 patients underwent microvascular decompression of the trigeminal nerve (MVD) with effectiveness in 75%.

CONCLUSIONS

We suggest that SUNCT and SUNA should be considered clinical phenotypes of the same syndrome. Brain MRI should always be performed with a dedicated view to exclude neurovascular compression. The high percentage of remission after MVD supports the pathogenetic role of neurovascular compression.

SUNCT, SUNA and pituitary tumors: Clinical characteristics and treatment

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.

Trigeminal autonomic cephalalgias: A review of recent diagnostic, therapeutic and pathophysiological developments

The trigeminal autonomic cephalalgias (TACs) are a group of primary headache disorders that are characterized by strictly unilateral trigeminal distribution pain occurring in association with ipsilateral cranial autonomic symptoms. This group includes cluster headache, paroxysmal hemicrania and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. These disorders are very painful, often considered to be some of the most painful conditions known to mankind, and consequently are highly disabling. They are distinguished by the frequency of attacks of pain, the length of the attacks and very characteristic responses to medical therapy, such that the diagnosis can usually be made clinically, which is important because it dictates therapy. The management of TACs can be very rewarding for physicians and highly beneficial to patients.

Italian guidelines for primary headaches: 2012 revised version

The first edition of the Italian diagnostic and therapeutic guidelines for primary headaches in adults was published in J Headache Pain 2(Suppl. 1):105–190 (2001). Ten years later, the guideline committee of the Italian Society for the Study of Headaches (SISC) decided it was time to update therapeutic guidelines. A literature search was carried out on Medline database, and all articles on primary headache treatments in English, German, French and Italian published from February 2001 to December 2011 were taken into account. Only randomized controlled trials (RCT) and meta-analyses were analysed for each drug. If RCT were lacking, open studies and case series were also examined. According to the previous edition, four levels of recommendation were defined on the basis of levels of evidence, scientific strength of evidence and clinical effectiveness. Recommendations for symptomatic and prophylactic treatment of migraine and cluster headache were therefore revised with respect to previous 2001 guidelines and a section was dedicated to non-pharmacological treatment. This article reports a summary of the revised version published in extenso in an Italian version.

Orofacial pain due to trigeminal autonomic cephalgia with features of short-lasting neuralgiform headache attacks with conjunctival injection and tearing: a case report

BACKGROUND

We present a case of a 64-year-old woman with a presumptive diagnosis of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome with telangiectasia. Dental procedures were not successful in alleviating the condition.

RESULTS

The patient's symptoms of short unilateral severe pain episodes abated after geographic relocation, although orofacial pain continued. Sphenoid sinus surgery further decreased the patient's chronic pain complaints. The patient's current pain condition is controlled with gabapentin therapy.

CLINICAL IMPLICATIONS

Diagnostic, etiologic, and therapeutic issues related to SUNCT syndrome are discussed. This case represents the first case report of trigeminal autonomic cephalgia with SUNCT syndrome-like features illustrating possible problematic dental therapies. It is only the third SUNCT case report in the dental literature, and the third case reporting a correlation between SUNCT syndrome and sinusitis.

SUNCT syndrome successfully treated by gamma knife radiosurgery: case report

BACKGROUND

The SUNCT syndrome (short-unilateral neuralgiform headache with conjunctival injection and tearing) can be very disabling for affected patients and is often refractory to medical management. We report the first case of SUNCT with a successful response to stereotactic radiosurgery without any adverse effect.

CASE

After failing optimal medical treatment, a 82-year old male patient suffering from SUNCT syndrome was treated with Gamma knife radiosurgery. The trigeminal nerve and sphenopalatine ganglion were targeted with a maximum dose of 80 Gy each. The patient had complete pain cessation 2 weeks after the treatment, and remains pain-free with no medication at the latest follow-up 39 months after radiosurgery. He did not have any side effect from the procedure.

CONCLUSION

Gamma knife radiosurgery is an option for medically refractory SUNCT patients.

[Japanese SUNCT patient responsive to gabapentin]

We report a Japanese patient with short lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUCNT) responsive to gabapentin. A 29-year-old man presented with sudden-onset intermittent left-sided orbital headache, which was not accompanied by lacrimation and conjunctival injection. We diagnosed trigeminal neuralgia at first and administered carbamazepine and loxoprofen. However, these medications were entirely ineffective at all and 6 days later, autonomic symptoms including conjunctival injection and tearing appeared. Diagnosis of SUNCT was made and gabapentin was started at up to 800 mg per day. Soon after, the headache and autonomic symptoms disappeared. Gabapantin at 800 mg per day was continued for 3 months and then reduced to 400 mg per day. Soon he had only a slight headache without tearing and conjunctival injection. He has continued to take gabapenin at 400 mg per day until now. This case indicated that headache and autonomic symptoms in SUNCT did not always emerge simultaneously, but they sometimes appear with time lag. Furthermore, the long-term clinical course and therapeutic outcome in SUNCT remain unknown. A therapeutic strategy and optimal dosage of medications including gabapentin should be established for the treatment of SUNCT.

The Role of Lamotrigine in the Treatment of Short-Lasting Unilateral Neuralgiform Headache Attacks with Conjunctival Injection and Tearing Syndrome

Objective

To evaluate the efficacy of lamotrigine for treatment of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome.

Data Sources:

Literature was accessed through MEDLINE (1950-June 2010) using the terms lamotrigine, triazines, SUNCT, and trigeminal autonomic cephalgia.

Study Selection And Data Extraction:

All articles in English and studies conducted in humans were identified and evaluated.

Data Synthesis:

SUNCT syndrome can be an extremely challenging headache type to manage and has been considered refractory to pharmacotherapy. Many anticonvulsants have been evaluated as promising SUNCT treatments, with lamotrigine specifically reported as an effective first-line treatment option. There is a lack of randomized placebo-controlled clinical trials evaluating lamotrigine in SUNCT syndrome therapy; however, 2 observational studies, 3 case series, and 5 case reports were reviewed. Lamotrigine appears to decrease the frequency and severity of SUNCT attacks, leading to complete resolution in some patients. A decrease in symptoms was achieved with doses ranging from 25 to 600 mg/day. In some cases, there was initial response to low doses, but dosage titrations were often necessary when symptoms returned several days after being managed at the same dose. Lamotrigine should be initiated at 25 mg/day and gradually titrated, guided by response and adverse effects. The risk of Stevens-Johnson syndrome, a dose-related adverse effect, can be minimized with gradual titration.

Conclusions:

According to case reports and observational studies, lamotrigine therapy has resulted in decreased frequency or resolution of SUNCT syndrome attacks. Randomized, controlled trials are necessary to confirm the efficacy of lamotrigine for this indication.

Epicrania fugax: ten new cases and therapeutic results

OBJECTIVE

We aimed to report 10 new cases of epicrania fugax (EF), showing their clinical features and therapeutic responses.

BACKGROUND

Epicrania fugax has been recently described as a paroxysmal head pain starting in a focal area located at a posterior cranial region and rapidly spreading forward to the ipsilateral eye or nose along a linear or zigzag trajectory. In some patients the pain is followed by ocular or nasal autonomic features. In the prior series, 1 patient got pain relief with anesthetic blockades, while another patient improved with carbamazepine.

METHODS

Since the first description of EF, we have assessed 10 patients with the same clinical picture (8 women and 2 men) at the Neurology outpatient offices of our 2 centers.

RESULTS

The mean age at onset was 48.5 years (SD: 19.8, range: 23-83). All the patients complained of strictly unilateral pain paroxysms starting at parietal (n = 5), occipital (n = 4), or parieto-occipital locations (n = 1), and immediately spreading forward through a linear pathway toward the ipsilateral forehead (n = 3) or the ipsilateral eye (n = 7), the complete sequence lasting 1-10 seconds. No trigger was identified in any of our patients, while 5 of them suffered mild pain in the stemming area between the paroxysms. Three patients had ipsilateral lacrimation, and 2 had conjunctival injection at the end of the attacks. The frequency ranged from 1 attack per week to multiple attacks per day. Neuroimaging and laboratory tests were consistently normal. Interictal pain was responsive to acetaminophen. In 3 cases a preventive was considered in order to avoid the paroxysms. Gabapentin led to significant improvement in 2 cases. The third patient did not obtain any benefit from gabapentin or amitriptyline, but improved slightly with lamotrigine.

CONCLUSIONS

This description reinforces the proposal of EF as a new headache variant or a new headache syndrome. Anesthetic blockades, carbamazepine, gabapentin, and lamotrigine have been apparently effective in individual patients. Further observations and therapeutic trials are needed.

Methylprednisolone therapy for short-term prevention of SUNCT syndrome

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) is characterized by severe and frequent daily pain attacks causing transient physical disability for the patients during the headache period. Currently there is no option for abortive treatment of the attacks, mainly due to the short-lived nature and frequency of the repeated headaches, while highly efficacious therapy is also unavailable for short-term prevention. We report rapidly suppressed headache attacks with orally administered methylprednisolone in eight headache periods of three patients with idiopathic, episodic SUNCT syndrome. The remission was maintained until the period was over in all cases. Although the mechanism of methylprednisolone action is unclear, it is probably based on the anti-inflammatory effects of the drug.

Trigeminal autonomic cephalalgias: a review and implications for dentistry

BACKGROUND

The authors review the epidemiology, clinical features, pathophysiology, diagnosis, treatment, orofacial presentations and dental implications of trigeminal autonomic cephalalgias (TACs): cluster headache (CH), paroxysmal hemicrania (PH) and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT).

TYPES OF STUDIES REVIEWED

The authors conducted PUBMED searches for the period from 1968 through 2007 using the terms "trigeminal autonomic cephalalgias," "cluster headache," "paroxysmal hemicrania," "short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing," "epidemiology," "pathophysiology," "treatment," "oral," "facial" and "dentistry." They gave preference to articles reporting randomized, controlled trials and those published in English-language peer-reviewed journals.

RESULTS

TACs refers to a group of headaches characterized by unilateral head pain, facial pain or both with accompanying autonomic features. Although their pathophysiologies are unclear, CH, PH and SUNCT may be differentiated according to their clinical characteristics. Current treatments for each of the TACs are useful in alleviating the pain, with few refractory cases requiring surgical intervention. Patients with TACs often visit dental offices seeking relief for their pain.

CLINICAL IMPLICATIONS

Although the prevalence of TACs is small, it is important for dentists to recognize the disorder and refer patients to a neurologist. This will avoid the pitfall of administering unnecessary and inappropriate traditional dental treatments in an attempt to alleviate the neurovascular pain.

Efficacy of Gabapentin in the Treatment of SUNCT Syndrome

This study was designed to evaluate the efficacy of gabapentin (GBP) in the treatment of SUNCT syndrome on a relatively large sample of Persian patients. Eight patients with SUNCT syndrome underwent a 4-week, open-label, daily treatment of 600-900 mg GBP. The frequency, intensity and duration of attacks were compared before and after the trial. After 4 weeks of treatment, intensity, duration and frequency of headaches were significantly ( P< 0.05) reduced. In addition, five patients (62.5±) were completely relieved from headaches, and in the other three patients the mean intensity, frequency and duration of headaches were decreased notably. In this study, GBP was well tolerated and no unfavourable side-effects were reported. After the end of the trial all patients continued the medication, and after 3 months none reported undesired side-effects or return of the headaches to the pre-treatment status. Our patients had a significant response to GBP, and considering other case reports on the effectiveness of GBP in the treatment of SUNCT syndrome, we propose that, taking into account the good side-effect profile and lack of interactions of GBP, this drug could be considered as an option for the treatment of SUNCT.

Short-lasting, unilateral neuralgiform headache attacks with conjunctival injection and tearing syndrome treated successfully with transsphenoidal resection of a growth hormone-secreting pituitary adenoma

Short-lasting, unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome was first described in 1978 as one of the trigeminal autonomic cephalgias. In this paper the authors present a patient with a growth hormone–secreting pituitary adenoma who experienced resolution of SUNCT syndrome after transsphenoidal tumor resection.

Trigeminal autonomic cephalalgias. Part 3: short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) is a syndrome characterized by severe, strictly unilateral short-lasting (between 5 and 240 seconds) pain localized to orbital, supraorbital, and temporal areas, accompanied by ipsilateral conjunctival injection and lacrimation. It represents 1 of 3 primary headaches classified as trigeminal autonomic cephalalgias (TACs). Although its prevalence is extremely small, SUNCT patients may present at dental offices seeking relief for their pain. It is important for oral health care providers to recognize SUNCT and render an accurate diagnosis. This will avoid the pitfall of implementing unnecessary and inappropriate traditional dental treatments in hopes of alleviating this neurovascular pain. The following article is part 3 of a review on TACs and focuses on SUNCT. Aspects of SUNCT, including epidemiology, genetics, pathophysiology, clinical presentation, classification and variants, diagnosis, medical management, and dental considerations are discussed.

Uso de gabapentina no tratamento da Síndrome SUNCT

Relatamos o caso clínico de duas mulheres com quadro compatível com síndrome SUNCT (cefaléia de curta duração, unilateral, neuralgiforme com hiperemia conjuntival e lacrimejamento). As duas apresentavam exames clínico e neurológico normais e RM com sinais de microangiopatia. A primeira apresentava cefaléia há três anos, que ocorria várias vezes por dia, sempre que mastigava ou bocejava. Havia feito uso várias medicações sem melhora. A dor foi controlada após o uso de 600 mg de gabapentina ao dia. A segunda paciente referia cefaléia há seis meses. A dor era diária, ocorrendo de 20-40 vezes por dia. Na ocasião da primeira avaliação no ambulatório, já fazia uso 600 mg de carbamazepina ao dia e 15 mg de clorpromazina, com melhora parcial. Após introdução de gabapentina- 1200 mg/ dia, a paciente evoluiu sem dor, porém com episódios de hiperemia conjuntival.

Trigeminal Autonomic Cephalalgias: Current and Future Treatments

The trigeminal autonomic cephalgias include cluster headache, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT). The evidence for the current treatment options for each of these syndromes is considered, including oxygen, sumatriptan, and verapamil in cluster headache, indomethacin in paroxysmal hemicrania, and intravenous lidocaine and lamotrigine in SUNCT. Some treatments such as topiramate have an effect in all of these, as well as in migraine and other pain syndromes. The involvement of the hypothalamus in functional imaging studies implies that this may be a substrate for targeting treatment options in the future.

Neuromodulatory approaches to the treatment of trigeminal autonomic cephalalgias

The trigeminal autonomic cephalalgias (TACs) are a group of primary headache syndromes characterised by intense pain and associated activation of cranial parasympathetic autonomic outflow pathways out of proportion to the pain. The TACs include cluster headache, paroxysmal hemicrania and SUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing). The pathophysiology of these syndromes involves activation of the trigeminal-autonomic reflex, whose afferent limb projects into the trigeminocervical complex in the caudal brainstem and upper cervical spinal cord. Functional brain imaging has shown activations in the posterior hypothalamic grey matter in TACs. This paper reviews the anatomy and physiology of these conditions and the brain imaging findings. Current treatments are summarised and the role of neuromodulation procedures, such as occipital nerve stimulation and deep brain stimulation in the posterior hypothalamus are reviewed. Neuromodulatory procedures are a promising avenue for these highly disabled patients with treatment refractory TACs.

Bilateral SUNCT syndrome associated to chronic maxillary sinus disease

SUNCT syndrome (short lasting unilateral neuralgiform headache with conjuntival injection and tearing) is defined as short attacks of periorbital unilateral pain and accompanied by ipsilateral lacrimation and redness of the same eye. We present an unusual SUNCT case with bilateral pain that started five years ago after an acute maxillary sinus infection that evolved to chronic sinusitis. This association has been described in few SUNCT cases, but its causal role remains uncertain. The patient was a 58 years old man that fulfilled a headache diary that showed the usual circadian pattern, worsening in the morning and afternoon, and responded to treatment with gabapentina. He was submitted to a functional endoscopic sinus surgery and evolved with milder pain. In a review of 21 patients, 5 had a past medical history of sinusitis, but the causal role of this association remained uncertain.

Cluster headache: a case-based review of diagnostic and treatment approaches

Cluster headache is one of the worst pain syndromes known to mankind. Medical treatment is highly effective in most cases, but because cluster headache is rare, many physicians are not familiar with the details of its management. This article reviews three common presentations of cluster headache to illustrate standard approaches to its treatment. Algorithms for acute, preventive, and transitional (bridge) therapy are provided.

SUNCT syndrome: an update

SUNCT (Shortlasting Unilateral Neuralgiform Headache attacks with Conjunctival injection and Tearing) is a syndrome characterised by shortlived (5-240 s), strictly unilateral, orbital/periorbital, moderate-to-severe pain attacks, accompanied by rapidly developing conjunctival injection and lacrimation. Most attacks are triggered by mechanical stimuli, but there are also spontaneous attacks. Symptomatic periods alternate with remissions in an unpredictable fashion. In active periods, the attacks predominate during daytime, with a frequency that ranges from < 1 attack/day to > 30 attacks/h SUNCT is mainly a primary disorder, but is sometimes associated with intracranial structural lesions (symptomatic SUNCT). SUNCT has been included in the group of trigeminal autonomic cephalalgias, which are thought to depend on the activation of the trigeminal system together with the disinhibition of a trigeminofacial autonomic reflex. According to a few reports, SUNCT patients may benefit from carbamazepine, lamotrigine, gabapentin, topiramate or various surgical procedures. However, well-designed clinical trials are required before these therapeutic options can be sufficiently validated.

Short-lasting Unilateral Neuralgiform Headache with Conjunctival Injection and Tearing Syndrome Treated with Microvascular Decompression of the Trigeminal Nerve: Case Report

OBJECTIVE AND IMPORTANCE

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing syndrome is a very rare disorder characterized by short-lasting neuralgiform unilateral pain affecting the orbital-periorbital area and associated with autonomic phenomena consisting mainly of conjunctival injection, tearing, and rhinorrhea. Treatment of this condition is difficult; many drugs and surgical procedures have been tried with variable results. In the literature, two cases have been described with short-term response to microvascular decompression of the trigeminal root. We present the case of a patient with short-lasting unilateral neuralgiform headache with conjunctival injection and tearing syndrome who remains asymptomatic 2 years after microvascular decompression.

CLINICAL PRESENTATION

A 56-year-old woman was referred to our clinic because she had experienced pain in the distribution of the first left trigeminal branch during the previous 2 years. She experienced paroxysms lasting from a few seconds to 1 to 2 minutes superimposed over a dull sensation of pain involving the same territory. The paroxysms had no refractory period and were triggered by touching the eye or the left side of the face, chewing, yawning, washing her hair, and even by light. Although the paroxysms were triggered by light touch or chewing, she was able to talk or touch herself while having the paroxysm. During pain attacks, she experienced tearing and ipsilateral conjunctival injection, eyelid edema and rhinorrhea, as well as intense photophobia. A magnetic resonance imaging scan revealed a vascular structure distorting and compressing the trigeminal root.

INTERVENTION

The patient underwent microvascular decompression of the trigeminal root. At surgery, there was clear compression of the trigeminal root by a superior cerebellar artery loop that was resolved by interposing a Teflon patch. The patient awoke from the operation without pain, and all the accompanying signs and symptoms, such as photophobia, disappeared. The postoperative course was uneventful, and 2 years after treatment, the patient remains asymptomatic.

CONCLUSION

Microvascular decompression could be an alternative therapeutic approach to this rare syndrome.

Gabapentin-responsive idiopathic stabbing headache

Idiopathic stabbing headache (ISH) is defined as the occurrence of short-lasting, painful jabs, restricted to the ophthalmic division of the trigeminal nerve. It is closely related to other forms of headache (such as migraine and tension-type headache) and has been reported among all age groups, including children and adolescents. As pathogenic mechanisms of the disease remain unclear, management decisions are empirical and limited to few options. Classically, indomethacin has been considered the first option, but therapeutic failure occurs in up to 35% of cases. In this setting, we report four patients with young-onset indomethacin-resistant ISH which had good responses to gabapentin and discuss the use of this drug in the presenting situation.