Short-lasting Unilateral Neuralgiform Headache Research Articles

Diagnosis and Clinical Features of Trigemino‐Autonomic Headaches

Although severe short-lasting headaches are rare, they can be considered disabling conditions with a major impact on the quality of life of patients. These headaches can divided broadly in to those associated with autonomic symptoms, so called trigeminal autonomic cephalgias (TACs), and those with few or no autonomic symptoms. The TACs include cluster headache, paroxysmal hemicranias, hemicrania continua, and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms as well as short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing syndrome. In all of these syndromes, half-sided head pain and ipsilateral cranial autonomic symptoms such as lacrimation or rhinorrhea are prominent. The paroxysmal hemicranias have, unlike cluster headaches, a very robust response to indomethacin, leading to a notion of indomethacin-sensitive headaches. The diagnosis of TACs is exclusively a clinical task. Because of the fact that cluster headache is strictly half-sided, typically involves the region around the eye and temple and often starts in the upper jaw, most patients first consult a dentist or ophthalmologist. No single instrumental examination has yet been able to define, or ensure, the correct diagnosis, or differentiate idiopathic headache syndromes. It is crucial that a trained neurologist sees these patients early so that management can be optimized and unnecessary procedures can be avoided. Although TACS are, in comparison to migraine, quite rare, they are nevertheless clinically very important for the neurologist to consider as they are easy to diagnose and the treatment is very effective in most patients.

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

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

A Case of Recurrent Facial Pain Associated With a Pourfour du Petit Syndrome: A New Entity?

We report the case of a 38-year-old woman with a history of migraine who experienced an association of recurrent unilateral facial pain and Pourfour du Petit syndrome. The episodes occurred for between a few seconds and up to 3 minutes up to 6 times a day mimicking short-lasting unilateral neuralgiform headaches with cranial autonomic symptoms. No lesional cause was found and the use of topiramate led to a nearly complete disappearance of the episodes. This new entity raises the question of a novel autonomic dysfunction in short-lasting unilateral neuralgiform headaches with cranial autonomic symptoms or an unexpected presentation of migraine.

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing caused by a pituitary adenoma

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) syndrome is a rare primary headache syndrome first described in 1978. We report on a 43-year-old man with a 10 year history of SUNCT in whom a pituitary macroadenoma was eventually detected. His pain rapidly improved with medical treatment of the prolactinoma and we propose that this is a case of symptomatic SUNCT.

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.

Frameless linac-based stereotactic radiosurgery treatment for SUNCT syndrome targeting the trigeminal nerve and sphenopalatine ganglion

The short-lasting unilateral neuralgiform headache associated with conjunctival injection and tearing or SUNCT syndrome was first described in the 1970s. This paper is the first in the literature that describes the successful use of stereotactic radiosurgery (SRS) using a non-invasive frameless technique, targeting both the trigeminal nerve and the sphenopalatine ganglion in the management of intractable SUNCT. We also discuss the role of selecting peripheral targets in the management of this rare headache syndrome. Among patients treated for functional pain disorders in our radiosurgery unit using the frameless technique since August 2011, one patient with symptoms matching the International Classification of Headache Disorders-2 (ICHD-II) criteria of SUNCT syndrome was identified. The multi-disciplinary case records of this patient were retrospectively reviewed and reported. Our patient had symptoms resembling the ICHD-II diagnostic criteria of SUNCT, which was refractory to medical treatment. Ninety Gy was delivered to the trigeminal root entry zone and 80 Gy was delivered to the sphenopalatine ganglion. At 16 months' follow-up, she was pain free with minimal side effects. Frameless linear accelerator (linac)-based SRS targeting the trigeminal nerve and sphenopalatine ganglion remained successful in our patient at 16 months. Longer follow-up and further experience will determine the efficacy and safety of this approach. We suggest that frameless SRS is a convenient and attractive non-invasive option for patients with medically refractory SUNCT.

Hemicrania Continua: Functional Imaging and Clinical Features With Diagnostic Implications.

This review focuses on summarizing 2 pivotal articles in the clinical and pathophysiologic understanding of hemicrania continua (HC). The first article, a functional imaging project, identifies both the dorsal rostral pons (a region associated with the generation of migraines) and the posterior hypothalamus (a region associated with the generation of cluster and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing [SUNCT]) as active during HC. The second article is a summary of the clinical features seen in a prospective cohort of HC patients that carry significant diagnostic implications. In particular, they identify a wider range of autonomic signs than what is currently included in the International Headache Society criteria (including an absence of autonomic signs in a small percentage of patients), a high frequency of migrainous features, and the presence of aggravation and/or restlessness during attacks. Wide variations in exacerbation length, frequency, pain description, and pain location (including side-switching pain) are also noted. Thus, a case is made for widening and modifying the clinical diagnostic criteria used to identify patients with HC.

Abstracts and Citations

This review focuses on summarizing 2 pivotal articles in the clinical and pathophysiologic understanding of hemicrania continua (HC). The first article, a functional imaging project,identifies both the dorsal rostral pons (a region associated with the generation of migraines) and the posterior hypothalamus(a region associated with the generation of cluster and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing [SUNCT]) as active during HC. The second article is a summary of the clinical features seen in a prospective cohort of HC patients that carry significant diagnostic implications. In particular, they identify a wider range of autonomic signs than what is currently included in the International Headache Society criteria (including an absence of autonomic signs in a small percentage of patients), a high frequency of migrainous features, and the presence of aggravation and/or restlessness during attacks. Wide variations in exacerbation length, frequency, pain description, and pain location (including side-switching pain) are also noted. Thus, a case is made for widening and modifying the clinical diagnostic criteria used to identify patients with HC.

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.

Both trigeminal autonomic cephalalgia and trigeminal neuralgia in a child

Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) are an uncommon syndrome [1] similar in frequency, duration, setting and severity to short-lasting unilateral neuralgiform headache attack with conjunctival injection and tearing (SUNCT syndrome). SUNCT and SUNA belong to a group of headache syndromes classified as Trigeminal Autonomic Cephalalgias (TACs) and were included in the second edition of the International Classification of Headache Disorders [2]. Some studies have focused on the association between Trigeminal Neuralgia (TN) and TACs with short-lasting attacks [3]. To our best knowledge, no cases of SUNA in childhood have been reported so far. We describe a child with a SUNA syndrome associated with TN probably triggered by inflammatory lesion of nasal mucosa. In April 2006, a 9-year-old child with Norrie disease [4] became agitated and complained of facial pain. Those attacks persisted for approximately half an hour, had a frequency of 2–3 per day and were refractory to NSAIDs. A few days before the beginning of attacks, the patient presented purulent rhinorrhea. An otorhinolaryngoiatric examination evidenced a piece of a toy into the right nostril. The toy was removed but it did not cure the pain. Ophthalmologic examination, brain magnetic resonance imaging, dental scan and EEG were normal. From September to November 2006, the child was treated with Pregabalin and then with Topiramate, without benefit on pain. At the time of our observation, in November 2006, the pain started to be well localized: it involved the forehead, the orbital and temporal region, prevalently on the right-side. Two types of attack were observed: single stabs (clusters with length of attack in range from a few seconds to 5 min) and another one lasting about 30 min. Some of the pain accesses were self-controlled by the patient by massaging the painful area. He had two to three attacks every day, with alternate prevalence of side: pain was accompanied by ipsilateral conjunctival injection (but not tearing), rhinorrhea, eyelid oedema and sweating. The patient was treated with various drugs (Pregabalin, Carbamazepine, Gabapentin), but only the association of Gabapentin and Lamotrigine modified the type of painful attacks. In fact, attacks affected the second division of the trigeminal nerve (V2) without cranial autonomic symptoms. Most of the attacks were still right-sided, lasting from a fraction of a second to 2 min, showing TN characteristics [2]. In June 2007, the accesses became more frequent and intense. The pain accesses were spontaneous or were triggered by the wind, chew, brushing, hot or cold feed. Oxcarbazepine (1200 mg/die) associated with Lamotrigine (200 mg/die) was introduced with a gradual discontinuation of Gabapentin, showing an almost complete remission. Reduction of therapy caused the reappearance of attacks so, at the moment, the child continues this therapy showing sporadic episodes of pain. The headache of this child fulfils the diagnostic criteria for chronic SUNA [2]. He has had more than 20 attacks R. Valeria P. Concetta P. Mariotti (&) Unit of Child Neuropsychiatry, Catholic University, L.go A. Gemelli, 8, 00168 Rome, Italy e-mail: pm@mclink.it

Management of Trigeminal Autonomic Cephalalgias in Children and Adolescents

Primary headache disorders that are more frequently encountered in the paediatric population include migraine and tension-type headaches. The trigeminal autonomic cephalalgias (TACs), which includes cluster headache (CH), paroxysmal hemicrania (PH) and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), are rarely reported in the paediatric population. The 1-year prevalence of CH seems to be 0.03 %. The clinical features of childhood and adolescence onset CH seem to be similar to those of adult onset. Cranial autonomic features and restlessness seem to less prominent in children than in adults. When restlessness is present, it often manifests as thrashing around in children and can distract attention from the headache, thereby contributing to a delay in diagnosis. The frequency of cluster periods seems to be lower in childhood. Similarly, the duration of the single cluster period seems to be shorter. The temporal pattern shows a trend towards a gradual increase of frequency and duration of symptoms in adult life. In terms of management of paediatric CH, oxygen has been used successfully in several paediatric CH patients, and given its good side-effect profile, it is considered the abortive agent of choice for paediatric CH. Verapamil is the preventative drug of choice in both episodic and chronic CH, though paediatric patients should be started on lower doses and titrated according to age. Paediatric-onset PH and SUNCT are very rarely reported. The clinical phenotype and response to treatment seem to resemble the adult-onset form. Paediatric-onset TACs are poorly recognized and there is often a delay of several months or years before the diagnosis is made. Awareness of typical clinical pictures of these excruciating headaches is essential to allow prompt initiation of the appropriate management.

Introduction: Cranial nerve surgery

In this issue of Neurosurgical Focus, we have compiled a group of interesting papers related to anatomy, physiology, pathology, and surgery of the cranial nerves. We were very pleased to receive many more submissions of excellent papers on this topic from which we had the difficult task of having to select, because of limitations in space, only 8 papers. Rodgers and colleagues give an excellent review of the syndrome of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. In the authors’ case, the syndrome was caused by an epidermoid tumor of the cerebellopontine angle that was clearly compressing the trigeminal nerve. We found this case report interesting because the etiology of this syndrome has not been clear, and this paper suggests that compression of the trigeminal nerve may be one of the causes. We thought that the excellent review of this topic the authors provide to us is important because neurosurgeons are so frequently called upon to treat trigeminal neuralgia, and we must be able to differentiate that condition from this interesting syndrome. Ross and colleagues report on 4 patients with rare facial nerve tumors and use the opportunity to present us with a nice review of the literature on the clinical syndrome, imaging characteristics, and surgical treatment of these tumors. Wang and colleagues from the University of Pittsburgh review their extensive experience with microvascular decompression for hemifacial spasm and conclude that botulinum toxin injections, which many of these patients underwent for treatment of their spasms before microvascular decompression, had no impact on the results of this operation. This finding is important because nowadays most patients have already had this type of palliative treatment before undergoing microvascular decompression. The second paper by this group of authors (Thirumala et al.) is a careful study of neurophysiological monitoring during microvascular decompression for hemifacial spasm; essentially, the authors conclude that changes in interpeak latency of brainstem auditory evoked potentials during surgery do not increase the odds of postoperative hearing loss and should not be used as an “alarm criteria” during microvascular decompression. Kshettry and colleagues present a nice historical review of the early studies of the anatomy of the petroclival region and the contributions of Primo Dorello, an Italian anatomist, after whom the Dorello canal is named. Interestingly, it turns out that the canal now widely known by Dorello’s name had been previously described 50 years earlier by W. Gruber. This paper also contains a nice review of anatomical studies of this region followed by a brief review of clinical implications. Schmidt et al. present a case of a malignant peripheral nerve sheath tumor of the trigeminal nerve, which they used as an opportunity to review the literature and summarize very nicely a total of 36 cases of malignant peripheral nerve sheath tumors of the trigeminal nerve. As expected, these tumors usually present with altered facial sensation and/or facial pain, and it appears that aggressive resection followed by radiation therapy offers the best chance for survival. Sarnthein and colleagues present another interesting paper concerning neurophysiological monitoring of facial nerve function during skull base surgery. In this careful study, the authors find that an intraoperative increase in the threshold for transcranial stimulation necessary to elicit a facial nerve motor evoked response is very specifically correlated with postoperative facial nerve dysfunction, and they suggest that such monitoring should be used in these operations in addition to the widely used direct electrical stimulation of the facial nerve. This issue also contains a very nice review of the neurosurgical options for management of glossopharyngeal neuralgia by Rey-Dios and Cohen-Gadol. The authors conclude that microvascular decompression is an excellent option but that when a convincing neurovascular conflict is not found, section of the glossopharyngeal nerve and the upper rootlets of the vagus nerve is a satisfactory alternative. (http://thejns.org/doi/abs/10.3171/2013.1.FOCUS1322)

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing syndrome secondary to an epidermoid tumor in the cerebellopontine angle

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome is classified under trigeminal autonomic cephalalgias. This rare headache syndrome is infrequently associated with secondary pathologies. In this paper the authors report on a patient with paroxysmal left retroorbital pain with associated autonomic symptoms of ipsilateral conjunctival injection and lacrimation, suggestive of SUNCT syndrome. After failed medical treatment an MRI sequence was obtained in this patient, demonstrating an epidermoid tumor in the left cerebellopontine angle. The patient's symptoms completely resolved after a gross-total resection of the tumor. This case demonstrates the effectiveness of resection as definitive treatment for SUNCT syndrome associated with tumoral compression of the trigeminal nerve. Early MRI studies should be considered in all patients with SUNCT, especially those with atypical signs and symptoms.

Where SUNCT Contacts TN: A Case Report

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) and trigeminal neuralgia (TN) are unilateral painful conditions that can share the same triggering factors, autonomic features and the main location, as well as the cyclically recurrent crises. Both these syndromes are associated with a high percentage of findings of vascular malformation touching the trigeminal nerve, suggesting a pathophysiological relationship. In this paper, we report a new case with the main purpose to shine a light on the pathophysiology of these conditions. Many authors described a SUNCT case deriving from TN or vice versa, suggesting that these conditions are strongly related. Every case of transformed TN or SUNCT should therefore be reported to gather and compare further information.

SUNCT and SUNA: Recognition and Treatment

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.

Pediatric Headache: A Review

1. Heidi K. Blume, MD, MPH 1. Division of Pediatric Neurology, Seattle Children’s Hospital and Research Institute, Seattle, WA. * Abbreviations: CSF: : cerebrospinal fluid ICH: : intracranial hemorrhage ICP: : intracranial pressure IIH: : idiopathic intracranial hypertension NDPH: : new daily persistent headache NSAID: : nonsteroidal anti-inflammatory drug SVT: : sinus venous thrombosis TAC: : trigeminal autonomic cephalalgia Headaches are common in children; while most are caused by a benign problem or primary headache disorder, headaches can be a sign of a serious underlying condition. Pediatricians must be aware of the most recent recommendations for evaluating and managing headaches. After reading this article, readers should be able to: 1. Understand the evaluation of a child who has headache. 2. Recognize the diagnostic criteria for pediatric migraine. 3. Recognize “red flags” for elevated intracranial pressure or other underlying conditions in the child who has headache. 4. Discuss treatment strategies for migraine, tension, and chronic headache disorders. Headaches are common in children and adolescents and are a frequent chief complaint in office and emergency department visits. The vast majority of childhood headaches are due to a primary headache disorder, such as migraine, or an acute, relatively benign process, such as viral infection. However, clinicians also need to consider other causes of headaches in children. Even when headaches are benign, they may cause significant dysfunction for the child and family and must be managed appropriately to minimize disability and optimize function. In this review, we discuss the epidemiology of childhood headache, evaluation of the child who has headaches, when to consider secondary headache syndromes, and the diagnosis and management of primary headache disorders such as migraine and tension-type headaches. Acute and chronic headaches are relatively common in children and adolescents, although estimates of the precise prevalence of headache and migraine vary widely. Depending on the study definition of headache, population involved, and time periods studied, 17% to 90% of children report headaches, with an overall prevalence of 58% reporting some form of headache in the past year. (1 …

SUNCT, SUNA and pituitary tumors: Clinical characteristics and treatment

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. All patients diagnosed with SUNCT or SUNA in the Calgary Headache Assessment and Management Program were reviewed. 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. 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.

Short-lasting unilateral neuralgiform headache attacks with conjunctiva injection and tearing presenting as sphenoiditis

Headaches secondary to paranasal sinus disease are a common problem in otolaryngology practice. However, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCTs) are an extremely rare presentation of sinusitis. We report for the first time an unusual case of acute sinusitis presenting with SUNCTs-like symptoms with radiographically-proven isolated ipsilateral sphenoiditis, without any other intracranial pathologies. This case demonstrates an additional spectrum of acute sinusitis, which should be familiar to the otolaryngologist population.

Trigeminal Autonomic Cephalalgias

This article covers the clinical manifestations and differential diagnosis of the trigeminal autonomic cephalalgias (TACs). TACs comprise a subgroup of primary headache disorders presenting with lateralized, often severe, pain accompanied by cranial autonomic features. The key syndromes are cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)/short-lasting unilateral neuralgiform headache attacks with cranial autonomic features (SUNA), and hemicrania continua. Lateralization of symptoms and signs is the key feature differentiating the TACs and migraine. When diagnosing a TAC, it is appropriate to consider underlying pituitary or pituitary region pathology. Cluster headache responds to oxygen and parenteral triptans, with verapamil having the most success for prevention. Paroxysmal hemicrania responds to indomethacin. SUNCT/SUNA responds to lamotrigine and topiramate. Hemicrania continua responds to indomethacin. TACs are a unique group of primary headache syndromes with individual features and specific responses to treatment that make their identification crucial for optimum management.

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

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. 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. 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.