Introduction: The management of short-lasting
unilateral neuralgiform headache attacks with
conjunctival injection and tearing (SUNCT) and shortlasting 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.
Methods: In this single-centre, non-randomised,
prospective open-label study, we evaluated and
compared the efficacy of oral and parenteral treatments
for SUNCT and SUNA in a real-world setting.
Additionally, single-arm meta-analyses of the available
reports of SUNCT and SUNA treatments were conducted.
Results: The study cohort comprised 161 patients.
Most patients responded to lamotrigine (56%),
followed by oxcarbazepine (46%), duloxetine (30%),
carbamazepine (26%), topiramate (25%), pregabalin
and gabapentin (10%). Mexiletine and lacosamide were
effective in a meaningful proportion of patients but
poorly tolerated. Intravenous lidocaine given for 7–10
days led to improvement in 90% of patients, whereas
only 27% of patients responded to a greater occipital
nerve block. No statistically significant differences in
responders were observed between SUNCT and SUNA.
In the meta-analysis of the pooled data, topiramate was
found to be significantly more effective in SUNCT than
SUNA patients. However, a higher proportion of SUNA
than SUNCT was considered refractory to medications at
the time of the topiramate trial, possibly explaining this
isolated difference.
Conclusions: We propose a treatment algorithm for
SUNCT and SUNA for clinical practice. The response to
sodium channel blockers indicates a therapeutic overlap
with trigeminal neuralgia, suggesting that sodium
channels dysfunction may be a key pathophysiological
hallmark in these disorders. Furthermore, the therapeutic
similarities between SUNCT and SUNA further support
the hypothesis that these conditions are variants of the
same disorder
