Trigeminal autonomic cephalalgias (TACs) are a group of primary headache disorders characterized by unilateral pain in the trigeminal nerve distribution, associated with ipsilateral cranial autonomic features.
Diagnostic criteria:
Classification of SUNA according to the second edition of the International Classification of Headache Disorders
A At least 20 attacks fulfilling criteria B–E |
B Attacks of unilateral orbital, supraorbital or temporal stabbing or pulsating pain lasting from 2 s to 10 min |
C Pain is accompanied by one of |
1. Conjunctival injection and/or lacrimation |
2. Nasal congestion and/or rhinorrhea |
3. Eyelid edema |
D Attacks occur with a frequency of ≥1 per day from more than half of the time |
E No refractory period follows attacks triggered from trigger areas |
F Not attributed to another disorder |
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.
Medication | Dose range | Labs / monitor | Side effects |
Acute | |||
IV lidocaine
|
1.5-3.5mg/kg/h 7-10 days | EEG mandatory during infusion | |
Greater Occipital Nerve Injection (GONI) | methylprednisolone 80mg + 2ml of 2% lidocaine | ||
Chronic | |||
Lamotrigine/Lamictal (SUNCT) 1st line | 25mg/day BID increased gradually. Max 600mg/d | Titrate slowly guided my response and adverse effects. |
Sleepiness, dizziness, headache, vertigo and ataxia, rash. Risk of Steven-Johnson syndrome can be minimized with gradual titration |
Topiramate |
Start 15-25 mg/hs; increase to max of 200mg/day in divided doses Another article said 700mg Max dose? 25 mg tablets take 1 tablet at night Day 7: take 1 in the AM and 1 in the PM Day 14: take 1 in the AM, 2 in the PM Day 21: take 2 in the AM, 2 in the PM MAX: 200 mg If symptoms stop with any prophylactic meds u can stop them but u may not be able to |
Monitor bicarb levels b/c it can lower them
Migraine preventative |
Side effects: cognitive difficulties, sedation, fatigue, kidney stones, weight loss
Can cause acute glaucoma (IF THIS HAPPENS STOP THE MED!) |
Gabapentin (SUNA) 1st line |
300 mg/day titrated up slowly by 300 mg/day every 3-5 days
(go from 300 mg/day q 1 day, then 300 mg BID for 1 day then 300 mg TID)
you can start it as low as 100 mg/day to avoid sedation
-administer it TID for effective blood level
Maximum dose: 3600 mg |
Monitor blood pressure in HTN patients (b/c of fluid retention)
Lower dose in pts with renal insufficiency, B/c the kidneys excrete it. |
Sedation, dizziness, ataxia, fluid retention |
Pregabalin | 25 mg TID; increase to 100-200 mg TID, increase dose every three days by one tab.Max 600mg/d | Helps with sleep | |
Lidocaine patches (5%) |
Three-tier algorithm of oral preventive treatments for short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (Lambru et al, 2021).
Medications (maximum dose) | |
---|---|
First-line treatment | Lamotrigine (up to 700 mg/day) |
Second-line treatments |
Oxcarbazepine (up to 2400 mg/day) Duloxetine (up to 120 mg/day) Carbamazepine (up to 1600 mg/day) Topiramate (up to 800 mg/day) |
Third-line treatments |
Gabapentin (up to 4800 mg/day) Pregabalin (up to 600 mg/day) Lacosamide (up to 400 mg/day) Mexiletine (up to 1200 mg/day) |
Jiménez Caballero, P. E., Portilla Cuenca, J. C., & Casado Naranjo, I. (2011). Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) secondary to epidermoid cyst in the right cerebellopontine angle successfully treated with surgery. The journal of headache and pain, 12(3), 385–387. https://doi.org/10.1007/s10194-011-0326-4
Lambru, G., Stubberud, A., Rantell, K., Lagrata, S., Tronvik, E., & Matharu, M. S. (2021). Medical treatment of SUNCT and SUNA: a prospective open-label study including single-arm meta-analysis. Journal of neurology, neurosurgery, and psychiatry, 92(3), 233–241. https://doi.org/10.1136/jnnp-2020-323999