The problem of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) management remains unsolved. Despite a myriad of therapeutic trials, no convincingly effective remedy for SUNCT and SUNA is available at present. Based on open-label communications, some patients seemed to benefit from some pharmacologic, interventional, or invasive procedures. Possible effective preventive drugs are carbamazepine, lamotrigine, gabapentin, and topiramate. At present, the drug of choice for SUNCT seems to be lamotrigine whereas SUNA may better respond to gabapentin. There is no available abortive treatment for the individual attacks. During the worst periods, intravenous lidocaine may decrease the flow of SUNCT/SUNA attacks. In SUNCT, bilateral blockade of the greater occipital nerve, and superior cervical ganglion opioid blockade have been reported as temporary/partially effective in one patient each. Botulinum toxin injected around the symptomatic orbit provided sustained relief to one patient. Owing to the scarcity of reports the results of these interventions should be taken as preliminary. Invasive therapy with interventions directed to the first division of the trigeminal nerve or Gasserian ganglion, with local anesthetics or alcohol, radiofrequency thermocoagulation, microvascular decompression, and gamma-knife neurosurgery, have been tried in the treatment of refractory SUNCT. Some patients seemed to benefit from such interventions, but one should still have a critical attitude to these claims since no convincing results have been obtained as yet. The few SUNCT patients who underwent deep brain hypothalamic stimulation obtained a substantial and persistent relief.
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Sjaastad O, Russell D, Horven I, Bunaes U. Multiple neuralgiform unilateral headache attacks associated with conjunctival injection and appearing in clusters. A nosological problem. Proceedings of the Scandinavian Migraine Society 1978; 31.
Sjaastad O, Saunte C, Salvesen R, et al. Shortlasting, unilateral, neuralgiform headache attacks with conjuntival injection, tearing, sweating and rhinorrhea. Cephalalgia. 1989;9:147–56.
Pareja JA, Sjaastad O. SUNCT syndrome. A clinical review. Headache. 1997;37:195–202.
Matharu MS, Cohen AS, Boes CJ, Goadsby PJ. Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing syndrome: a review. Curr Pain Headache Rep. 2003;7:308–18.
Pareja JA, Cuadrado ML. SUNCT syndrome. An update. Expert Opin Pharmacother. 2005;6:591–9.
Goadsby PJ, Cittadini E, Burns B, Cohen AS. Trigeminal autonomic cephalalgias: diagnostic and therapeutic developments. Curr Opin Neurol. 2008;21:323–30.
Goadsby PJ, Cittadini E, Cohen AS. Trigeminal autonomic cephalalgias: paroxysmal hemicrania, SUNCT/SUNA, and hemicrania continua. Semin Neurol. 2010;30:186–91.
Goadsby PJ. Trigeminal autonomic cephalalgias. Continuum (Minneap Minn). 2012;18:3–95.
Pareja JA, Pareja J, Palomo T, et al. SUNCT syndrome. Repetitive and overlapping attacks. Headache. 1994;34:114–6.
Pareja JA, Sjaastad O. SUNCT syndrome in the female. Headache. 1994;34:217–20.
Laín AH, Caminero AB, Pareja JA. SUNCT syndrome. Absence of refractory periods and modulation of attack duration by lengthening of the trigger stimuli. Cephalalgia. 2000;20:671–3.
Pareja JA, Shen JM, Kruszewski P, et al. SUNCT syndrome. Duration, frequency and temporal distribution of attacks. Headache. 1996;36:161–5.
Cohen AS, Matharu MS, Goadsby PJ. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) or cranial autonomic features (SUNA)- a prospective clinical study of SUNCT and SUNA. Brain. 2006;129:2746–60.
Goadsby PJ, Lipton RB. A review of paroxysmal hemicranias, SUNCT syndrome and other short-lasting headaches with autonomic feature, including new cases. Brain. 1997;120:193–209.
International Headache Society. The international classification of headache disorders, 2nd edition. Cephalalgia. 2004;24 Suppl 1:1–160.
May A, Bahra A, Büchel C, et al. Functional magnetic resonance imaging in spontaneous attacks of SUNCT: short-lasting neuralgiform headache with conjunctival injection and tearing. Ann Neurol. 1999;46:791–3.
Massiou H, Launay JM, Levy C, et al. SUNCT syndrome in two patients with prolactinomas and bromocriptine-induced attacks. Neurology. 2002;58:1698–9.
Larner AJ. Headache induced by dopamine agonists prescribed for prolactinoma: think SUNCT! Int J Clin Pract. 2006;60:360–1.
Jiménez Caballero PE. SUNCT syndrome in a patient with prolactinoma and cabergoline-induced attacks. Cephalalgia. 2007;27:76–8.
Pareja JA, Kruszewski P, Sjaastad O. SUNCT syndrome: trials of drugs and anesthetic blockades. Headache. 1995;35:138–42.
Matharu MS, Boes CJ, Goadsby PJ. Management of trigeminal autonomic cephalalgias and hemicrania continua. Drugs. 2003;63:1637–77.
Pareja JA, Caminero AB, Sjaastad O. SUNCT syndrome. Diagnosis and treatment. CNS Drugs. 2002;16:373–83.
Leone M, Franzini A, D’Andrea G, et al. Deep brain stimulation to relieve drug-resistant SUNCT. Ann Neurol. 2005;57:924–7.
Cohen AS. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. Cephalalgia. 2007;27:824–32.
Dora B. SUNCT syndrome with dramatic response to oxcarbazepine. Cephalalgia. 2006;26:1171–3.
D’Andrea G, Granella F, Cadaldini M. Possible usefulness of lamotrigine in the treatment of SUNCT syndrome. Neurology. 1999;53:1609.
D’Andrea G, Granella F, Ghiotto N, Nappi G. Lamotrigine in the treatment of SUNCT syndrome. Neurology. 2001;57:1723–5.
Leone M, Rigamonti A, Usai D, et al. Two new SUNCT cases responsive to lamotrigine. Cephalalgia. 2000;20:845–7.
May A, Leone M, Afra J, et al. EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias. Eur J Neurol. 2006;13:1066–77.
Gutiérrez-García JM. SUNCT syndrome responsive to lamotrigine. Headache. 2002;42:823–5.
Malik K, Rizvi S, Vaillancourt PD. The SUNCT syndrome: successfully treated with lamotrigine. Pain Med. 2002;3:167–8.
Chakravarty A, Mukherjee A. SUNCT syndrome responsive to lamotrigine: documentation of the first Indian case. Cephalalgia. 2003;23:474–5.
Piovesan EJ, Siow C, Kowacs PA, Werneck LC. Influence of lamotrigine over the SUNCT syndrome: one patient follow-up for two years. Arq Neuropsiquiatr. 2003;61:691–4.
Rosselli JL, Karpinski JP. The role of lamotrigine in the treatment of short lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing syndrome. Ann Pharmacother. 2011;45:108–13. A thorough review article dealing with the treatment of SUNCT with lamotrigine that provided a resolution of symptoms or a substantial improvement in the frequency of attacks.
Graff-Radford SB. SUNCT syndrome responsive to gabapentin (Neurontin). Cephalalgia. 2000;20:515–7.
Porta-Etessam J, Benito-Leon J, Martinez-Salio A, Berbel A. Gabapentin in the treatment of SUNCT syndrome. Headache. 2002;42:523–4.
Rocha Filho PA, Rabello GD, Galvão AC, et al. Gabapentin in the treatment of SUNCT syndrome. Arq Neuropsiquiatr. 2007;65:503–5.
Hunt CH, Dodick DW, Bosch EP. SUNCT responsive to gabapentin. Headache. 2002;42:525–6.
Volcy M, Tepper SJ, Rapoport A, et al. Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA)—a case report. Cephalalgia. 2005;25:470–2.
Etemadifar M, Maghzi AH, Ghasemi M, et al. Efficacy of gabapentin in the treatment of SUNCT syndrome. Cephalalgia. 2008;28:1339–42.
Cohen AS, Matharu MS, Goadsby PJ. Suggested guidelines for treating SUNCT and SUNA. Cephalalgia. 2005;25:1200.
Rossi P, Cesarino F, Faroni J, et al. SUNCT syndrome successfully treated with topiramate: case reports. Cephalalgia. 2003;23:998–1000.
Kuhn J, Vosskaemper M, Berwemeyer H. SUNCT syndrome: a possible bilateral case responding to topiramate. Neurology. 2005;64:2159.
Matharu MS, Boes CJ, Goadsby PJ. SUNCT syndrome: prolonged attacks, refracttoriness and response to topiramate. Neurology. 2002;58:1307.
Ikawa M, Imai N, Manaka S. A case of SUNCT syndrome responsive to zonisamide. Cephalalgia. 2011;31:501–3.
Matharu MS, Cohen AS, Goadsby PJ. SUNCT syndrome responsive to intravenous lidocaine. Cephalalgia. 2004;24:985–92.
Williams MH, Broadley SA. SUNCT and SUNA: Clinical features and medical treatment. J Clin Neurosci. 2008;15:526–34.
Arroyo AM, Durán XR, Beldarrain MG, et al. Response to intravenous lidocaine in a patient with SUNCT syndrome. Cephalalgia. 2010;30:110–2.
Marmura MJ. Intravenous lidocaine and mexiletine in the management of trigeminal autonomic cephalalgias. Curr Pain Headache Rep. 2010;14:145–50.
Porta-Etessam J, Cuadrado ML, Galán L, et al. Temporal response to bupivacaine great occipital block in a patient with SUNCT syndrome. J Headache Pain. 2010;11:179.
Sabatowski R, Huber M, Meuser T, Radbruch L. SUNCT syndrome: a treatment option with local opioid blockade of the superior cervical ganglion? A case report. Cephalalgia. 2001;21:154–6.
Morales-Asín F, Espada F, López-Obarrio LA, et al. A SUNCT case with response to surgical treatment. Cephalalgia. 2000;20:67–8.
Baabor M, Rosas CS, Pérez-Limonte L. SUNCT responsive to percutaneous balloon compression of the gasserian ganglion–10-year follow-up. Headache. 2010;50:143–5.
Ertsey C, Bozsik G, Afra J, Jelencsik I. A case of SUNCT syndrome with neurovascular compression. Cephalalgia. 2000;20:325.
Hannerz J, Linderoth B. Neurosurgical treatment of short-lasting, unilateral, neuralgiform hemicrania with conjunctival injection and tearing. Br J Neurosurg. 2002;16:55–8.
Effendi K, Jarjoura S, Mathieu D. SUNCT syndrome successfully treated by gamma knife radiosurgery: case report. Cephalalgia. 2011;31:870–3.
Mathew T, Srinivas D, Aroor S, et al. SUNCT syndrome treated with gamma knife targeting the trigeminal nerve and sphenopalatine ganglion. J Headache Pain. 2012;13:491–2.
Lenarest M, Diederich N, Phuoe D. A patient with SUNCT cured by the Jannetta procedure. Cephalalgia. 1997;17:460.
Gardella L, Viruega A, Nagel J. A case of a patient with SUNCT syndrome treated with Jannetta procedure. Cephalalgia. 2001;21:996–9.
Lagares A, Gómez PA, Pérez-Núñez A, et al. Short-lasting Unilateral Neuralgiform Headache with Conjunctival Injection and Tearing Syndrome treated with microvascular decompression of the trigeminal nerve: case report. Neurosurgery. 2005;56:E413.
Sprenger T, Valet M, Platzer S, et al. SUNCT: Bilateral hypothalamic activation during headache attacks and resolving of symptoms after trigeminal decompression. Pain. 2005;113:422–6.
Irimia P, González-Redondo R, Dominguez PD, et al. Microvascular decompression may be effective for refractory SUNCT regardless of symptom duration. Cephalalgia. 2010;30:626–30.
Williams M, Bazina R, Tan L, Rice H, Boroadley SA. Microvascular decompression of the trigeminal nerve in the treatment of SUNCT and SUNA. J Neurol Neurosurg Psychiatry. 2010;81:998–6. According to the data presented in this report a substantial number of SUNCT and SUNA patients improved after decompression of the trigeminal nerve.
Leone M, Franzini A, D’Andrea G, et al. Deep brain stimulation to relieve drug-resistant SUNCT. Ann Neurol. 2005;57:924–7.
Lyons MK, Dodick DW, Evidente VG. Responsiveness of short lasting unilateral neuralgiform headache with conjunctival injection and tearing to hypothalamic deep brain stimulation. J Neurosurg. 2009;110:279–81.
Bartsch T, Falk D, Knudsen K, Reese R, Raethjen J, Mehdorn HM, Volkmann J, Deuschl G. Deep brain stimulation of the posterior hypothalamic area in intractable short-lasting unilateral neuralgiform headache with conjunctival injection and tearing. Cephalalgia. 2011;31:1405–8. Present and previous communications by Leone and Lyons indicate that deep brain stimulation of the posterior hypothalamus can be effective in the treatment of chronic refractory SUNCT.
Leone M, Franzini A, Proietti Cecchini A, et al. Deep brain stimulation in trigeminal autonomic cephalalgias. Neurotherapeutics. 2010;7:220–8.
Black DF, Dodick DW. Two cases of medically and surgically intractable SUNCT: a reason for caution and an argument for a central mechanism. Cephalalgia. 2002;22:201–4.
Hannerz J, Greitz D, Hansson P, Ericson K. SUNCT may be another manifestation of orbital venous vasculitis. Headache. 1992;32:384–9.
Raimondi E, Gardella L. SUNCT syndrome. Two cases in Argentina. Headache. 1998;38:369–71.
Salazar JA, Tamayo JA, Fernandez O. SUNCT type headache. A report of a new case. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. Neurologia. 1998;13:148–50.
Narbone MC, Gangemi S, Abbate M. A case of SUNCT syndrome responsive to verapamil. Cephalalgia. 2005;25:476–8.
Jiménez-Huete A, Franch O, Pareja JA. SUNCT syndrome: Priming of symptomatic periods and worsening of symptoms by treatment with calcium channel blockers. Cephalalgia. 2002;22:812–4.
Trauninger A, Alkonyi B, Kovács N, Komoly S. Methylprednisolone therapy for short-term prevention of SUNCT syndrome. Cephalalgia. 2010;30:735–9.
De Lourdes Figuerola M, Bruera O, Pozzo MJ, Leston J. SUNCT syndrome responding absolutely to steroids in two cases with different etiologies. J Headache Pain. 2009;10:55–7.
Rozen TD, Saper JL, Sheftell FD, Dodick DW. Clomiphene citrate as a new treatment for SUNCT: hormonal manipulation for hypothalamic-influenced trigeminal autonomic cephalalgias. Headache. 2005;45:754–6.
Schwaag S, Frese A, Husstedt IW, Evers S. SUNCT syndrome: the first German case series. Cephalalgia. 2003;23:398–400.
Zabalza RJ. Sustained response to botulinum toxin in SUNCT syndrome. Cephalalgia. 2012;32:869–72.
Sékhara T, Pelc K, Mewasingh LD, Boucquey D, Dan B. Pediatric SUNCT syndrome. Pediatr Neurol. 2005;33:206–7.
Unalp A, Ozturk AA. SUNCT syndrome in a child: a rare cause of paroxysmal headache. Ann Saudi Med. 2008;28:386–7.
Blättler T, Capone Mori A, Boltshauser E, Bassetti C. Symptomatic SUNCT in an eleven-year-old girl. Neurology. 2003;60:2012–3.
Sciruicchio V, Sardaro M, Gagliardi D, et al. A case of early onset and monophasic trigeminal autonomic cephalalgia: could it be a SUNCT? J Headache Pain. 2010;11:363–5.
Martino GH. SUNCT syndrome (Short lasting unilateral neuralgiform headache with conjunctival injection and tearing): a rare case in a pediatric patient with favourable response to topiramato. Arch Argent Pediatr. 2008;106:40–6.
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Pareja, J.A., Álvarez, M. & Montojo, T. SUNCT and SUNA: Recognition and Treatment. Curr Treat Options Neurol 15, 28–39 (2013). https://doi.org/10.1007/s11940-012-0211-8
- Trigeminal neuralgia
- Trigemino-autonomic cephalgias
- Greater occipital nerve blockade
- Superior cervical opioid ganglion blockade
- Botulinum toxin
- Trigeminal radiofrequency thermocoagulation
- Gasserian glycerol ganglyolisis
- Ballon compression of the trigeminal root
- Ballon compression of the Gasserian ganglion
- Trigeminal microvascular decompression
- Gamma-knife radiosurgery
- Hypothalamic stimulation