Similarities and differences between SUNCT and SUNA: a cross-sectional, multicentre study of 76 patients in China

Epidemiology and clinical features of short-lasting unilateral neuralgiform headache attacks: A systematic review and meta-analysis

BACKGROUND

To synthesize the available epidemiologic data on short-lasting unilateral neuralgiform headache attacks (SUNHA). This, in turn, might inform diagnostic work-up and clinical decision-making.

METHODS

EMBASE and PubMed were searched for observational studies reporting on the prevalence or relative frequency of SUNHA or its individual clinical features. Two investigators independently conducted title and abstract screening, full-text review, data extraction, and risk of bias assessment, and random-effects meta-analyses were performed to estimate the prevalence or relative frequency of SUNHA and its individual clinical features.

RESULTS

Fifteen clinic-based studies met our eligibility criteria. Of these, five studies reported estimates on the relative frequency of SUNHA among adults evaluated for headache or facial pain, yielding a pooled relative frequency as 0.32% (95% confidence interval = 0.17-0.62; I2 = 89.9%). Most often, SUNHA presented as episodic, side-locked stabbing headache of severe pain intensity, predominantly affecting the ophthalmic and/or maxillary branch of the trigeminal nerve. The most common cranial autonomic features were lacrimation, conjunctival injection, rhinorrhea and nasal congestion.

CONCLUSIONS

SUNHA is a rare headache disorder with distinct clinical features. However, our findings must be interpreted with caution as a result of between-study heterogeneity and lack of population-based studies, underscoring the need for further epidemiologic research.

Cluster Headache, SUNCT, and SUNA

OBJECTIVE

This article reviews the epidemiology, clinical features, differential diagnosis, pathophysiology, and management of three types of trigeminal autonomic cephalalgias: cluster headache (the most common), short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA).

LATEST DEVELOPMENTS

The first-line treatments for trigeminal autonomic cephalalgias have not changed in recent years: cluster headache is managed with oxygen, triptans, and verapamil, and SUNCT and SUNA are managed with lamotrigine. However, new successful clinical trials of high-dose prednisone, high-dose galcanezumab, and occipital nerve stimulation provide additional options for patients with cluster headache. Furthermore, new genetic and imaging tests in patients with cluster headache hold promise for a better understanding of its pathophysiology.

ESSENTIAL POINTS

The trigeminal autonomic cephalalgias are a group of diseases that appear similar to each other and other headache disorders but have important differences. Proper diagnosis is crucial for proper treatment.

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.

A Retrospective Comparative Study in Patients with SUNA and SUNCT

Introduction

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 headache disorders.

Aim

The aim of the study is to describe and compare the clinical characteristics of patients with SUNA and SUNCT.

Methods

Patients with SUNCT or SUNA observed in a neurology clinic of a tertiary hospital in India between January 2017 and December 2022 were evaluated.

Results

Thirteen patients with SUNA (seven female, 54%) and 16 patients with SUNCT (nine female, 56%) were identified for the evaluation. The mean ages at the onset of SUNA and SUNCT were 36.8.5 ± 8.1 years and 37.2 ± 8.4 years, respectively. The age of onset in our patients was somewhat younger than that of other large series. The demographic and clinical features of SUNA patients were comparable to those of SUNCT patients. Orbital/retro-orbital area was the most common site of pain in both types of headaches. The pattern of pain was noted as single stab (in all patients), repetitive stabs (SUNA vs. SUNCT: 77% vs. 75%), and sawtooth patterns (SUNA vs. SUNCT: 23% vs. 25%). The majority of attacks in both groups lasted less than two minutes. Conjunctival injection and tearing were present in all SUNCT patients (as a part of the diagnostic criteria). The prevalence of conjunctival injection and tearing in SUNA was 46% and 31%, respectively. All patients reported spontaneous attacks. Triggers were reported in seven (54%) patients with SUNA and nine (56%) with SUNCT. Only one patient in each group had a refractory period following a trigger-induced episode. Two patients in the SUNCT group had compression of the trigeminal nerve by a vascular loop.

Conclusion

This is the largest case series from India. There were no significant differences between patients with SUNA and SUNCT.