SUNCT and SUNA

What do SUNCT and SUNA mean?

SUNCT and SUNA belong to the trigeminal autonomic cephalalgias (TACs). Attacks are brief, intense and often occur many times throughout the day.

SUNCT describes attacks with conjunctival injection and tearing; SUNA describes attacks with other cranial autonomic symptoms, without necessarily having both eye redness and tearing.

Why they can be confused with trigeminal neuralgia

Their very short duration, stabbing or electric quality and possible triggers can resemble trigeminal neuralgia. Autonomic symptoms and the attack pattern help distinguish them.

Clinical features

Treatment

Medication is the first line of treatment. Lamotrigine is generally regarded as the reference treatment; other options may be used according to the individual case. Very severe cases may require intensive specialist or transitional treatment.

When are they considered refractory?

SUNCT and SUNA can be difficult to control. Before considering an interventional approach, it is essential to confirm the diagnosis, exclude secondary causes and check that medication treatments have been adequate.

The role of interventional pain management

In refractory SUNCT/SUNA, the priorities remain confirming the diagnosis, excluding secondary causes and checking that medication has been used appropriately. Interventional procedures are not a standard treatment, but may be considered in selected, particularly complex cases.

When the trigeminal-autonomic phenotype is pronounced and consistent with the clinical presentation, pulsed radiofrequency of the sphenopalatine ganglion (SPG) may be considered as a neuromodulation technique. The indication must remain individual and based on the clinical findings as a whole; where appropriate, the response to a transmucosal SPG diagnostic test may help with target selection. The available evidence is more limited than for medication and comes mainly from selected case series and specialist experience.