Treatment of SUNCT/SUNA, Paroxysmal Hemicrania, and Hemicrania Continua: An Update Including Single-Arm Meta-analyses

Abstract

Purpose of ReviewThis review presents a critical appraisal of the treatment strategies for short-lasting unilateral neuralgiform headache attacks (SUNHA), paroxysmal hemicrania (PH), and hemicrania continua (HC). We assess the available, though sparse, evidence on both medical and surgical treatments. In addition, we present estimated pooled analyses of the most common treatments and emphasize recent promising findings.Recent FindingsThe majority of literature available on the treatment of these rare trigeminal autonomic cephalalgias are small open-label observational studies and case reports. Pooled analyses reveal that lamotrigine for SUNHA and indomethacin for PH and HC are the preventative treatments of choice. Second-line choices include topiramate, gabapentin, and carbamazepine for SUNHA; verapamil for PH; and cyclooxygenase-2 inhibitors and gabapentin for HC. Parenteral lidocaine is highly effective as a transitional treatment for SUNHA. Novel therapeutic strategies such as non-invasive neurostimulation, targeted nerve and ganglion blockades, and invasive neurostimulation, including implanted occipital nerve stimulators and deep brain stimulation, appears to be promising options.SummaryAt present, lamotrigine as a prophylactic and parenteral lidocaine as transitional treatment remain the therapies of choice for SUNHA. While, by definition, both PH and CH respond exquisitely to indomethacin, evidence for other prophylactics is less convincing. Evidence for the novel emerging therapies is limited, though promising.