SUNCT Syndrome Responsive to Intravenous Lidocaine

SUNCT, SUNA and short-lasting unilateral neuralgiform headache attacks: Debates and an update

BACKGROUND

Short-lasting unilateral neuralgiform headache attacks (SUNHA) have the features of both short-lasting unilateral neuralgiform pain, such as trigeminal neuralgia or stabbing headache, and associated trigeminal autonomic symptoms, such as paroxysmal hemicrania or cluster headache. Recognizing and adequately treating SUNHA is essential but current treatment methods are ineffective in treating SUNHA.

METHODS

We reviewed the changes in the concept of short-lasting unilateral neuralgiform headache attacks and provide a narrative review of the current medical and surgical treatment options, from the first choice of treatment for patients to treatments for selective intractable cases.

RESULTS

Unlike the initial impression of an intractable primary headache disorder affecting older men, SUNHA affects both sexes throughout their lifespan. One striking feature of SUNHA is that the attacks are triggered by cutaneous or intraoral stimulation. The efficacy of conventional treatments is disappointing and challenging, and preventive therapy is the mainstay of treatment because of highly frequent attacks of a very brief duration. Amongst them, lamotrigine is effective in approximately two-third of the patients with SUNHA, and intravenous lidocaine is essential for the management of acute exacerbation of intractable pain. Topiramate, oxcarbazepine and gabapentin are considered good secondary options for SUNHA, and botulinum toxin can be used in selective cases. Neurovascular compression is commonly observed in SUNHA, and surgical approaches, such as neurovascular compression, have been reported to be effective for intractable cases.

CONCLUSIONS

Recent advances in the understanding of SUNHA have improved the recognition and treatment approaches for this unique condition.

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).

A single infusion of intravenous lidocaine for primary headaches and trigeminal neuralgia: a retrospective analysis

Introduction

Intravenous (IV) lidocaine has been used as a transitional treatment in headache and facial pain conditions, typically as an inpatient infusion over several days, which is costly and may increase the risk of adverse effects. Here we report on our experience using a single one-hour IV lidocaine infusion in an outpatient day-case setting for the management of refractory primary headache disorders with facial pain and trigeminal neuralgia.

Methods

This is a retrospective, single-center analysis on patients with medically refractory headache with facial pain and trigeminal neuralgia who were treated with IV lidocaine between March 2018 and July 2022. Lidocaine 5 mg.kg-1 in 60 mL saline was administered over 1 h, followed by an observation period of 30 min. Patients were considered responders if they reported reduction in pain intensity and/or headache frequency of 50% or greater. Duration of response was defined as short-term (< 2 weeks), medium-term (2-4 weeks) and long-term (> 4 weeks).

Results

Forty infusions were administered to 15 patients with trigeminal autonomic cephalalgias (n = 9), chronic migraine (n = 3) and trigeminal neuralgia (n = 3). Twelve patients were considered responders (80%), eight of whom were complete responders (100% pain freedom). The average duration of the treatment effect for each participant was 9.5 weeks (range 1-22 weeks). Six out of 15 patients reported mild and self-limiting side effects (40%).

Conclusion

A single infusion of IV lidocaine might be an effective and safe transitional treatment in refractory headache conditions with facial pain and trigeminal neuralgia. The sustained effect of repeated treatment cycles in some patients may suggest a role as long-term preventive therapy in some patients.

Short-lasting unilateral neuralgiform headache attacks (SUNCT/SUNA): a narrative review of interventional therapies

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache with autonomic symptoms (SUNA) are disabling primary headache disorders. The advent of advanced imaging technologies and surgical techniques has translated to a growing arsenal of interventional therapies capable of treating headache disorders. This literature review sheds light on the current evidence available for interventional therapies in medically intractable SUNCT/SUNA. PubMed and EMBASE were searched for publications between 1978 and 2022. Inclusion criteria were SUNCT/SUNA studies reporting outcomes following occipital nerve stimulation (ONS), pulsed radiofrequency (PRF) of sphenopalatine ganglion (SPG), stereotactic radiosurgery (SRS), deep brain stimulation (DBS) or microvascular decompression (MVD) of the trigeminal nerve. A greater than 50% reduction in severity or a greater than 50% reduction in the number of attacks was defined as a successful response. The rate of successful responses for the various treatment modalities were as follows: ONS 33/41 (80.5%), PRF of SPG 5/9 (55.6%), DBS of the ventral tegmental area 14/16 (86.7%), SRS to the SPG and/or trigeminal nerve 7/9 (77.8%) and MVD 56/73 (76.7%). Mean follow-up time in months was 42.5 (ONS), 24.8 (PRF), 25.3 (DBS), 20.8 (SRS) and 42.4 (MVD). A significant proportion of SUNCT/SUNA patients remain refractory to medical therapy (45%-55%). This review discusses existing literature on interventional approaches, including neuromodulation, radiofrequency ablation, gamma knife radiosurgery and MVD. The outcomes are promising, yet limited data exist, underscoring the need for further research to develop a robust surgical management algorithm.

SUNCT/SUNA in Pediatric Age: A Review of Pathophysiology and Therapeutic Options

The International Classification of Headache Disorders, 3rd edition (ICHD3) defines Short-lasting Unilateral Neuralgiform Headache Attacks (SUNHA) as attacks of moderate or severe, strictly unilateral head pain lasting from seconds to minutes, occurring at least once a day and usually associated with prominent lacrimation and redness of the ipsilateral eye. Two subtypes of SUNHA are identified: 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 pathologies are infrequent in children and difficult to diagnose. The authors reviewed the existing literature on SUNCT and SUNA, especially in the developmental age, which describes the pathophysiology in detail and focuses on the therapeutic options available to date. SUNHA-type headaches must be considered on the one hand, for the possibility of the onset of forms secondary to underlying pathologies even of a neoplastic nature, and on the other hand, for the negative impact they can have on an individual’s quality of life, particularly in young patients. Until now, published cases suggest that no chronic variants occur in childhood and adolescents. In light of this evidence, the authors offer a review that may serve as a source to be drawn upon in the implementation of suitable treatments in children and adolescents suffering from these headaches, focusing on therapies that are non-invasive and as risk-free as possible for pediatric patients.

Intravenous lidocaine vs. NSAIDs for migraine attack in the ED: a prospective, randomized, double-blind study

PURPOSE

Although different forms of lidocaine are used for migraine attack headaches, the effect of intravenous lidocaine is still limited. This study aimed to investigate the effects of intravenous lidocaine infusion for the treatment of migraine attack headaches.

METHODS

A hundred patients with migraine attacks, aged between 18 and 65, were randomly divided into two groups. The lidocaine group (n = 50) received a 1.5 mg/kg lidocaine bolus and a 1 mg/kg infusion (first 30 min), followed by a 0.5 mg/kg infusion for a further 30 min intravenously. The non-steroidal anti-inflammatory drug (NSAID) group (n = 50) received 50 mg dexketoprofen trometamol and saline at the same volume as the lidocaine at the same time intervals intravenously. The Visual Analog Scale (VAS) pain scores, additional analgesia requirement, side effects, and revisits to the emergency department were recorded.

RESULTS

The VAS score was significantly lower in the lidocaine group than in the NSAID group for the first 20th and 30th minutes (p = 0.014 and p = 0.024, respectively). There was no difference between the VAS scores for the remaining evaluation times (p > 0.05). In terms of secondary outcomes, rescue medication requirement was not different between the two groups at both the 60th and 90th minutes (p > 0.05). However, the number of patients revisiting ED within 48-72 h was statistically less in the lidocaine group than in the NSAID group (1/50 vs. 8/50; p = 0.031).

CONCLUSION

Intravenous lidocaine may be an alternative treatment method for patients with migraine attack headaches in the emergency department.

SUNCT and SUNA: An Update

Background

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache with autonomic symptoms (SUNA) are rare and disabling primary headache disorders that are subtypes of Short-lasting unilateral neuralgiform headache attacks (SUNHA).

Aim

The aim of this narrative review was to provide a comprehensive update on headache phenotype, pathophysiology, and various treatment options available for SUNCT and SUNA.

Methods

References for this review were identified by searches of articles published in the English language in PubMed between 1978 and October 2020 using "short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)", "short-lasting unilateral neuralgiform headache with autonomic symptoms (SUNA)", "short-lasting unilateral neuralgiform headache attacks (SUNHA)", "trigeminal autonomic cephalalgias" as keywords in various combinations.

Results

Of a potential 1103 articles, seven case series describing clinical characteristics of SUNCT/SUNA patients were identified for this review. For symptomatic/secondary SUNCT/SUNA, 53 individual case reports, and one case series were reviewed. One placebo-controlled trial and 11 open-label case series that evaluated various medical and surgical treatments in SUNCT/SUNA were also reviewed. Available literature suggests that SUNCT and SUNA are subtypes of the same disorder characterized by severe side locked short duration headache with ipsilateral prominent cranial autonomic symptoms and signs. Pathophysiology may involve both peripheral and central mechanisms. Lamotrigine is the most effective preventive therapy while intravenous lidocaine is the most efficacious drug as transitional therapy for severe disabling attacks. Surgical options including microvascular decompression in those having neurovascular conflict, occipital nerve stimulation, and hypothalamic deep brain stimulation can be alternative treatment options for medically refractory patients.

Medical treatment of SUNCT and SUNA: a prospective open-label study including single-arm meta-analysis

INTRODUCTION

The management 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) remains challenging in view of the paucity of data and evidence-based treatment recommendations are missing.

METHODS

In this single-centre, non-randomised, prospective open-label study, we evaluated and compared the efficacy of oral and parenteral treatments for SUNCT and SUNA in a real-world setting. Additionally, single-arm meta-analyses of the available reports of SUNCT and SUNA treatments were conducted.

RESULTS

The study cohort comprised 161 patients. Most patients responded to lamotrigine (56%), followed by oxcarbazepine (46%), duloxetine (30%), carbamazepine (26%), topiramate (25%), pregabalin and gabapentin (10%). Mexiletine and lacosamide were effective in a meaningful proportion of patients but poorly tolerated. Intravenous lidocaine given for 7-10 days led to improvement in 90% of patients, whereas only 27% of patients responded to a greater occipital nerve block. No statistically significant differences in responders were observed between SUNCT and SUNA. In the meta-analysis of the pooled data, topiramate was found to be significantly more effective in SUNCT than SUNA patients. However, a higher proportion of SUNA than SUNCT was considered refractory to medications at the time of the topiramate trial, possibly explaining this isolated difference.

CONCLUSIONS

We propose a treatment algorithm for SUNCT and SUNA for clinical practice. The response to sodium channel blockers indicates a therapeutic overlap with trigeminal neuralgia, suggesting that sodium channels dysfunction may be a key pathophysiological hallmark in these disorders. Furthermore, the therapeutic similarities between SUNCT and SUNA further support the hypothesis that these conditions are variants of the same disorder.

Utilization of Intravenous Lidocaine Infusion for the Treatment of Refractory Chronic Pain

Context

Chronic pain accounts for one of the most common reasons patients seek medical care. The financial burden of chronic pain on health care is seen by direct financial cost and resource utilization. Many risk factors may contribute to chronic pain, but there is no definite risk. Managing chronic pain is a balance between maximally alleviating symptoms by utilizing a therapeutic regimen that is safe for long-term use. Currently, non-opioid analgesics, NSAIDs, and opioids are some of the medical treatment options, but these have numerous adverse effects and may not be the best option for long-term use. However, Lidocaine can achieve both central and peripheral analgesic effects with relatively few side effects, which may be an ideal compound for managing chronic pain.

Evidence Acquisition

This is a Narrative Review.

Results

Infusion of lidocaine (2-(diethylamino)-N-(2,6-dimethylphenyl)acetamide), an amino-amide compound, is emerging as a promising option to fill the therapeutic void for treatment of chronic pain. Numerous studies have outlined dosing protocols for lidocaine infusion for the management of perioperative pain, outlined below. While there are slight variations in these different protocols, they all center around a similar dosing regimen to administer a bolus to reach a rapid steady state, followed by infusion for up to 72 hours to maintain the therapeutic analgesic effects.

Conclusions

Lidocaine may be a promising pharmacologic solution with a low side effect profile that provides central and peripheral analgesia. Even though the multifaceted mechanism is not entirely understood yet, lidocaine may be a promising novel remedy in treating chronic pain in various conditions.

SUNCT/SUNA: Case series presenting in an orofacial pain clinic

AIM

Little is known about short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA). We present our experience with SUNCT/SUNA patients to aid identification and management of these disorders.

METHODS

A retrospective review of patient records of one orofacial pain clinic was performed. Inclusion criteria was a diagnosis of SUNCT/SUNA confirmed with at least one follow-up visit.

RESULTS

Six of the 2464 new patients seen between 2015-2018 met the selection criteria (SUNCT n = 2, SUNA n = 4). Gender distribution was one male to one female and average age of diagnosis was 52 years (range 26-62). Attacks were located in the V1/V2 trigeminal distributions, and five patients reported associated intraoral pain. Pain quality was sharp, shooting, and burning with two patients reporting "numbness". Pain was moderate-severe in intensity, with daily episodes that typically lasted for seconds. Common autonomic features were lacrimation, conjunctival injection, rhinorrhea, and flushing. Frequent triggers were touching the nose or a specific intraoral area. Lamotrigine and gabapentin were commonly used as initial therapy.

CONCLUSIONS

Differentiating between SUNCT/SUNA does not appear to be clinically relevant. Presenting symptoms were consistent with those published, except 5/6 patients describing intraoral pain and two patients describing paresthesia.

Short-Lasting Unilateral Neuralgiform Headache Attacks with Conjunctival Injection and Tearing (SUNCT) Status Like Condition: A Rare Case Report and Review of the Literature

Background:

SUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing) is rare trigeminal autonomic cephalgia characterized by recurrent, brief, excruciating unilateral, intermittent headache paroxysms over orbital, frontal or temporal region occurring multiple times per day and it can rarely present as “SUNCTstatus like condition” (SSLC).

Case Report:

A 28-year old male with a history of SUNCT headache for 6 months presented with left forehead stabs lasting for 30 seconds with a frequency of 40-45 episodes per hour for three days followed by infective gastroenteritis. His neurological examination was normal, except left-sided ptosis, tearing, and conjunctival injection. His MRI brain with contrast, MR angiography, and laboratory investigations were unremarkable except mild hypokalemia. He was treated with intravenous fluids, potassium replacement, and high dose methylprednisolone along with an escalated dose of carbamazepine.

Review and Conclusion:

We have reviewed the previously reported seven cases and our case of SSLC. Female: Male ratio was 3:1and the mean age was 40.87 years. Three patients responded to high dose steroids and three to lignocaine along with rapid escalation or change of anticonvulsant drugs. One case responded to the high dose of lamotrigine, and in a pregnant lady, the pain subsided only after the termination of the pregnancy. One case was secondary to multiple sclerosis, while the rest of seven were primary episodic SSLC. The condition is highly disabling, and the treatment with steroids or lignocaine, along with the rapid escalation of preventive drugs, can provide long-lasting relief

Short-Lasting Unilateral Neuralgiform Headache Attacks with Conjunctival Injection and Tearing (SUNCT) Status Like Condition: A Rare Case Report and Review of the Literature

Background:

SUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing) is rare trigeminal autonomic cephalgia characterized by recurrent, brief, excruciating unilateral, intermittent headache paroxysms over orbital, frontal or temporal region occurring multiple times per day and it can rarely present as “SUNCTstatus like condition” (SSLC).

Case Report:

A 28-year old male with a history of SUNCT headache for 6 months presented with left forehead stabs lasting for 30 seconds with a frequency of 40-45 episodes per hour for three days followed by infective gastroenteritis. His neurological examination was normal, except left-sided ptosis, tearing, and conjunctival injection. His MRI brain with contrast, MR angiography, and laboratory investigations were unremarkable except mild hypokalemia. He was treated with intravenous fluids, potassium replacement, and high dose methylprednisolone along with an escalated dose of carbamazepine.

Review and Conclusion:

We have reviewed the previously reported seven cases and our case of SSLC. Female: Male ratio was 3:1and the mean age was 40.87 years. Three patients responded to high dose steroids and three to lignocaine along with rapid escalation or change of anticonvulsant drugs. One case responded to the high dose of lamotrigine, and in a pregnant lady, the pain subsided only after the termination of the pregnancy. One case was secondary to multiple sclerosis, while the rest of seven were primary episodic SSLC. The condition is highly disabling, and the treatment with steroids or lignocaine, along with the rapid escalation of preventive drugs, can provide long-lasting relief

A systematic review of rescue analgesic strategies in acute exacerbations of primary trigeminal neuralgia

BACKGROUND

Trigeminal neuralgia (TN) can have a significant impact on wellbeing and quality of life. Limited data exist for treatments that improve TN pain acutely, within 24 h of administration. This systematic review aims to identify effective treatments that acutely relieve TN exacerbations.

METHODS

We searched Medline and Cochrane Central Register of Controlled Trials (CENTRAL) for relevant English language publications. The reference list for all articles was searched for other relevant publications. All studies that satisfied the following PICO criteria were included: (i) Population-adults with acute exacerbation of primary TN symptoms; (ii) Intervention-any medication or intervention with the primary goal of pain relief within 24 h; (iii) Comparator-usual medical care, placebo, sham or active treatment; (iv) Outcome-more than 50% reduction in pain intensity within 24 h of administration.

RESULTS

Of 431 studies, 17 studies were identified that reported immediate results of acute treatment in TN. The evidence suggests that the following interventions may be beneficial: local anaesthetic, mainly lidocaine (ophthalmic, nasal or oral mucosa, trigger point injection, i.v. infusion, nerve block); anticonvulsant, phenytoin or fosphenytoin (i.v. infusion); serotonin agonist, sumatriptan (s.c. injection, nasal). Other referenced interventions with very limited evidence include N-methyl-d-aspartate receptor antagonist (magnesium sulphate infusion) and botulinum toxin (trigger point injection).

CONCLUSIONS

Several treatment options exist that may provide fast and safe relief of TN. Future studies should report on outcomes within 24 h to improve knowledge of the acute analgesic TN treatments.

Dramatic response of intravenous lidocaine in a patient with status like SUNA

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 primary headaches that can sometimes present with a status like pattern which can be highly disabling. Intravenous (IV) lidocaine has been reported to be useful in status like SUNCT but its use in status like SUNA remains unexplored. We report a patient of episodic SUNA who despite on multiple conventional drugs had status like presentation. He had an excellent sustained response to IV lidocaine. Relevant literature on treatment of status like SUNCT/SUNA is briefly reviewed. IV lidocaine can be a very useful treatment for status like SUNA.

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.

Termination of SUNCT with intravenous lignocaine followed by oral mexiletine

Background:

The trigeminal autonomic cephalalgias (TACs) are a group of debilitating, pathophysiologically similar headache syndromes characterized by facial pain and autonomic symptoms in areas supplied by the trigeminal nerve. Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) is among the rarest of the TAC syndromes and can be particularly recalcitrant to treatment.

Case:

We describe the case of a 50-year old woman with difficult-to-control SUNCT whose pain was completely aborted within hours of commencing intravenous lignocaine therapy and was maintained pain-free after transitioning to oral mexiletine.

Conclusion:

This is the first report of successful transition from intravenous lignocaine to oral mexiletine in SUNCT, and we suggest that this treatment should be tried early in difficult-to-control SUNCT. This therapy is safe, effective and with minimal side effects if administered in an appropriate manner.

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.

Long-term follow up of intractable chronic short lasting unilateral neuralgiform headache disorders treated with occipital nerve stimulation

Background Occipital nerve stimulation is a potential treatment option for medically intractable short-lasting unilateral neuralgiform headache attacks. We present long-term outcomes in 31 patients with short-lasting unilateral neuralgiform headache attacks treated with occipital nerve stimulation in an uncontrolled open-label prospective study. Methods Thirty-one patients with intractable short-lasting unilateral neuralgiform headache attacks were treated with bilateral occipital nerve stimulation from 2007 to 2015. Data on attack characteristics, quality of life, disability and adverse events were collected. Primary endpoint was change in mean daily attack frequency at final follow-up. Results At a mean follow-up of 44.9 months (range 13-89) there was a 69% improvement in attack frequency with a response rate (defined as at least a 50% improvement in daily attack frequency) of 77%. Attack severity reduced by 4.7 points on the verbal rating scale and attack duration by a mean of 64%. Improvements were seen in headache-related disability and depression. Adverse event rates were favorable, with no electrode migration or erosion reported. Conclusion Occipital nerve stimulation appears to offer a safe and efficacious treatment for refractory short-lasting unilateral neuralgiform headache attacks with significant improvements sustained in the long term. The procedure has a low adverse event rate when conducted in highly specialised units.

Increased rate of venous thrombosis may be associated with inpatient dihydroergotamine treatment

OBJECTIVE

To review whether the incidence of catheter-associated venous thromboses was higher in patients receiving IV dihydroergotamine compared to lidocaine.

METHODS

We retrospectively reviewed all admissions at the University of California, San Francisco Headache Center from February 25, 2008, through October 31, 2014, for age, sex, diagnosis, aura, treatment dose, type of IV line used, days with line, superficial (SVT) or deep venous thrombosis (DVT), and pulmonary embolism (PE).

RESULTS

A peripherally inserted central catheter (PICC) or midline catheter was placed in 315 of 589 (53%) admissions. Mean age was 38 years with a range of 6 to 79 years; 121 patients (21%) were ≤18 years old. Seventy-four percent (433 of 589) of patients were female. Of 263 dihydroergotamine admissions using a PICC or midline catheter, 19 (7.2%) had either an SVT or DVT or a PE; 2 patients were diagnosed with both DVT and PE. Of 52 lidocaine admissions using a PICC or midline catheter, none had a thrombotic event (p = 0.05, Fisher exact test). Age, sex, aura, total dihydroergotamine dose, and number of days with line were not significant predictors of venous thrombosis.

CONCLUSIONS

IV dihydroergotamine treatment may be associated with an increased risk of catheter-associated venous thrombosis. A low threshold for diagnostic ultrasound investigation is appropriate because anticoagulation therapy was frequently required.

SUN: Short-Lasting Unilateral Neuralgiform Headache Attacks

PREMISE

Short-lasting unilateral neuralgiform headache attacks (SUN) are part of the group of primary headaches called trigeminal autonomic cephalalgias (TACs). They are characterized by unilateral attacks of pain with associated ipsilateral cranial autonomic symptoms.

PROBLEM

Recently the classification of these attacks has changed, to incorporate the different types of autonomic symptoms such as conjunctival injection and tearing (or lack thereof). Previously considered to be rare and rather refractory to treatment, there is an increasing awareness of this syndrome and the therapeutic possibilities.

DISCUSSION

This article discusses the clinical aspects of the syndrome, pathophysiology, current, and future treatments.

Trigeminal Autonomic Cephalalgias

PURPOSE OF REVIEW

This article reviews the clinical features of and treatment options for the trigeminal autonomic cephalalgias (TACs).

RECENT FINDINGS

The TACs are a group of primary headache disorders characterized by short-lasting episodes of severe unilateral headaches that are associated with ipsilateral cranial autonomic symptoms. The best known and most commonly seen TAC in clinical practice is cluster headache. The other syndromes within this group include paroxysmal hemicrania, hemicrania continua, and short-lasting unilateral neuralgiform headache attacks. Although these disorders share a similar phenotype, they are distinguished by differences in attack frequency and duration. Recognition of these clinical differences is paramount because treatment options vary; paroxysmal hemicrania and hemicrania continua demonstrate an absolute response to treatment with indomethacin, while the other syndromes respond to other agents.

SUMMARY

Although much less common than other headache disorders seen in clinical practice, recognition of the TACs is especially important as they are among the most severe and disabling syndromes in headache medicine.

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.

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

Background. Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) syndrome is an unusual cause of headache, mainly described in older adults, and is rare in children. Pain attacks may be severe, frequent, and prolonged. The therapeutic benefits of many drugs are disappointing. Patient and Methods. A 12-year-old boy suffered severe headache and toothache for 20 days. As treatment with nonsteroidal anti-inflammatory drugs, anticonvulsants, and steroids proved ineffective, he was treated with ipsilateral multisite subcutaneous injections of botulinum toxin A 70 U around the orbit, the temporal area, and the upper gum. Results. The pain had reduced in frequency and severity by the fourth day after treatment and had completely disappeared after 7 days. There were no side effects or recurrence during a subsequent 17-month follow-up period. Conclusion. Botulinum toxin A can be used to treat the first episode of SUNCT in children over the age of 12 years.

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.

Tic versus TAC: differentiating the neuralgias (trigeminal neuralgia) from the cephalalgias (SUNCT and SUNA)

Trigeminal neuralgia, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with autonomic symptoms (SUNA) are classified as distinct disorders in the International Classification of Headache Disorders 3 beta (ICHD-3 beta). SUNCT and SUNA are primary headache disorders included among the trigeminal autonomic cephalalgias. Trigeminal neuralgia is classified under painful cranial neuropathies and other facial pains. The classification criteria of these conditions overlap significantly which could lead to misdiagnosis. The reported overlap among these conditions has called into question whether they should be considered distinct entities or rather a continuum of the same disorder. This review explores the known overlap and how other features not included in the ICHD-3 beta criteria may better differentiate the "Tics" (trigeminal neuralgia) from the "TACs" (SUNCT and SUNA).

Trigeminal autonomic cephalalgias: beyond the conventional treatments

The trigeminal autonomic cephalalgias include cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks, and hemicrania continua. While the majority responds to conventional pharmacological treatments, a small but significant proportion of patients are intractable to these treatments. In these cases, alternative choices for these patients include oral and injectable drugs, lesional or resectional surgery, and neurostimulation. The evidence base for conventional treatments is limited, and the evidence for those used beyond convention is more so. At present, the most evidence exists for nerve blocks, deep brain stimulation, occipital nerve stimulation, sphenopalatine ganglion stimulation in chronic cluster headache, and microvascular decompression of the trigeminal nerve in short-lasting unilateral neuralgiform headache attacks.

Migraine and epilepsy: review of the literature

Migraine and epilepsy are disorders that are common, paroxysmal, and chronic. In many ways they are clearly different diseases, yet there are some pathophysiological overlaps, and overlaps in clinical symptomatology, particularly with regard to visual and other sensory disturbances, pain, and alterations of consciousness. Epidemiological studies have revealed that the two diseases are comorbid in a number of individuals. Both are now recognized as originating from electrical disturbances in the brain, although their wider manifestations involve the recruitment of multiple pathogenic mechanisms. An initial excess of neuronal activity in migraine leads to cortical spreading depression and aura, with the subsequent recruitment of the trigeminal nucleus leading to central sensitization and pain. In epilepsy, neuronal overactivity leads to the recruitment of larger populations of neurons firing in a rhythmic manner that constitutes an epileptic seizure. Migraine aura and headaches may act as a trigger for epileptic seizures. Epilepsy is not infrequently accompanied by preictal, ictal, and postictal headaches that often have migrainous features. Genetic links are also apparent between the two disorders, and are particularly evident in the familial hemiplegic migraine syndromes where different mutations can produce either migraine, epilepsy, or both. Also, various medications are found to be effective for both migraine and epilepsy, again pointing to a commonality and overlap between the two disorders.

An unusual case of episodic SUNCT responding to high doses of topiramate

Trigeminal autonomic cephalalgias (TAC) are rare. Cluster headaches comprise the majority, with short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) being the rarest and shortest in duration. The majority of SUNCT are primary with a few cases occurring secondary to posterior fossa or pituitary lesions. Although activities like exercise or blowing of the nose can trigger SUNCT, onset during orgasm has not been described. Short-lasting aura has been described in TACs including SUNCT, but persistence of focal symptoms and signs without an underlying structural lesion have not been described. Lastly, treatment of SUNCT is difficult, with lamotrigine being the most common effective reported. We report a case of episodic SUNCT with symptoms suggestive of brainstem stroke that completely resolved spontaneously for which no underlying structural cause was found. The onset of first attack occurred during orgasm, and the patient responded to a high dose of topiramate.

Trigeminal autonomic cephalalgias

The trigeminal autonomic cephalalgias (TACs) are a group of primary headache disorders characterised by lateralized symptoms: prominent headache and ipsilateral cranial autonomic features, such as conjunctival injection, lacrimation and rhinorrhea. The TACs are: cluster headache (CH), paroxysmal hemicrania (PH), short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)/short-lasting neuralgiform headache attacks with cranial autonomic features (SUNA) and hemicrania continua (HC). Their diagnostic criteria are outlined in the International Classification of Headache Disorders, third edition-beta (ICHD-IIIb). These conditions are distinguished by their attack duration and frequency, as well as response to treatment. HC is continuous and by definition responsive to indomethacin. The main differential when considering this headache is chronic migraine. Other TACs are remarkable for their short duration and must be distinguished from other short-lasting painful conditions, such as trigeminal neuralgia and primary stabbing headache. Cluster headache is characterised by exquisitely painful attacks that occur in discrete episodes lasting 15-180 min a few times a day. In comparison, PH occurs more frequently and is of shorter duration, and like HC is responsive to indomethacin. SUNCT/SUNA is the shortest duration and highest frequency TAC; attacks can occur over a hundred times every day.

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.

Role of trigeminal microvascular decompression in the treatment of SUNCT and SUNA

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) are primary headache disorders. Evidence suggests that SUNCT/SUNA have similar pathophysiology to the trigeminal autonomic cephalalgias and involves the trigeminal autonomic reflex. This review provides an overview of microvascular decompression of the trigeminal nerve and other surgical therapeutic options for SUNCT/SUNA. We have undertaken a mini-meta-analysis of available case reports and case series with the aim of providing recommendations for the use of such therapies in SUNCT/SUNA. There is some evidence supporting microvascular decompression of the trigeminal nerve in selected patients who have medically refractory SUNCT/SUNA and a demonstrable ipsilateral aberrant vessel on magnetic resonance imaging (MRI). We also consider what further investigations could be undertaken to assess the role of surgical interventions in the treatment of these often debilitating conditions.

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.

Trigeminal autonomic cephalalgias other than cluster headache

Trigeminal autonomic cephalalgias are short-lasting primary headache disorders associated with autonomic symptoms. Paroxysmal hemicrania is a rare headache disorder similar to cluster headache. 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 unusual headache syndromes typified by a high frequency of severe, brief, unilateral attacks that usually occur in the distribution of the trigeminal nerve. SUNCT is a subtype of SUNA in which both conjunctival injection and tearing are present. SUNA differs from SUNCT in that autonomic symptoms are less prominent.

[A Japanese SUNA patient with migraine without aura and medication overuse headache responsive to topiramate]

A 34-year-old woman presented with new intermittent short lasing headache around the left eye accompanied with lacrimation. She suffered from anemia and visual disturbance due to thalassaemia beta heterotype and retinitis pigmentosa. She also had continual cephalalgia from about 9 years old, and was taking nonsteroidal anti-inflammatory drug almost every day. After the medical treatment, we diagnosed her headache as migraine without aura, medication overuse headache (MOH) and short lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA). Triptan was effective for a migraine headache, but it was ineffective for attacks of SUNA, while topiramate dramatically reduced the SUNA attacks. A headache diary was effective to evaluate the clinical course and the effect of treatment for two different types of headaches by devising the approach to description. A migraine and MOH may coexist with SUNA, and our attention should be paid to the diagnosis and medical treatment in such cases.

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.

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.

Intravenous lidocaine and mexiletine in the management of trigeminal autonomic cephalalgias

Lidocaine and mexiletine are class 1B antiarrhythmic drugs that act on sodium channels. Lidocaine is also an important anesthetic and topical agent that is useful in the treatment of multiple pain disorders, and mexiletine is commonly used for neuropathic pain and myotonia. Both intravenous lidocaine and mexiletine are increasingly used to treat pain syndromes and appear to be particularly effective in neuropathic pain. This suggests a role for these agents in patients with headache disorders. This article describes the role of intravenous lidocaine and mexiletine in the management of headache and trigeminal autonomic cephalalgias based on the published literature to date and provides practical guidelines for their use.

Acute and preventive treatment of cluster headache and other trigeminal autonomic cephalgias

Patients with cluster headache or any of the trigeminal autonomic cephalalgias (TACs) are often good candidates for preventive treatment as their headaches are frequent and severe. While acute and symptomatic therapies must be used often, they do not alter the course of the cluster period or the duration of the TACs, and they do not usually decrease the frequency of attacks. In this chapter we discuss the aim and the choice of prevention. Verapamil is considered the first choice for prevention of cluster headache, but as with all of the medications to be mentioned, it has various adverse effects to be aware of. Other frequently used preventives for cluster include lithium carbonate, methysergide where available, methylergonovine, clonidine, melatonin, valproate, gabapentin, topiramate, and others. Several other medications can be used as bridge therapy, to decrease the frequency of cluster temporarily, giving time for the preventives to begin to work. The most commonly used bridge therapies are 7-21 days of prednisone at high and then tapering doses and ergots such as ergotamine tartrate and dihydroergotamine. Patients with chronic cluster headache who are unresponsive to all medical therapies can be considered for occipital nerve stimulation and various surgical procedures such as ganglyogliolysis of all three branches of the ipsilateral trigeminal nerve at the root entry zone. A somewhat controversial but highly successful procedure, at least as done by the neurosurgeons in Professor Bussone's group at the Institute of Neurology in Milan, has been deep-brain stimulation of the posterior hypothalamus. Other TACs, such as short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), can be hard to treat effectively with medications, but the paroxysmal hemicranias and cluster tic respond somewhat better to traditional therapies.

Bilateral SUNCT-like headache in a patient with prolactinoma responsive to lamotrigine

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) syndrome is a rare trigeminal autonomic cephalalgia. The cases of SUNCT with attacks that affected both sides simultaneously have only rarely been reported and some of them had underlying pathology. We have reported a case of bilateral SUNCT-like headache secondary to a prolactinoma and responsive to lamotrigine treatment.

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.