Short-Lasting Unilateral Neuralgiform Headache with Conjunctival Injection and Tearing Secondary to Head and Neck Trauma: Literature Review and Case Report

This article reports a case of secondary short-lasting unilateral neuralgiform headache with conjunctival injection and tearing following head and neck trauma due to a violent assault. Following the incident, the patient began experiencing 4 to 30 shooting/sharp pain attacks per day in the left anterior temporal and supraorbital areas, with an intensity of 10/10 on a numeric rating scale. Each attack lasted between 10 and 60 seconds. These attacks were accompanied by ipsilateral conjunctival injection, tearing, ptosis of the left eye, blurry vision, and occasional rhinorrhea. Significant improvements in sleep, autonomic symptoms, and pain were observed with a combination of melatonin 10 mg per day, gabapentin 300 mg twice daily, physical therapy, and psychotherapy. This case highlights the relevance of a multidisciplinary approach in the treatment of challenging cases when there is evidence of more than one contributing factor, with the aim of reducing pain and improving the patient’s quality of life.

cervical trauma; gabapentin; melatonin; short-lasting unilateral neuralgiform headache with conjunctival injection and tearing; trigeminal-autonomic cephalalgias

1. Sjaastad O, Saunte C, Salvesen R, et al. Shortlasting unilateral neuralgiform headache attacks with conjunctival injection, tearing, sweating, and rhinorrhea. Cephalalgia 1989;9:147–156.

2. Lambru G, Matharu M. SUNCT and SUNA: Medical and surgical treatments. Neurol Sci 2013;34(suppl 1):S75–S81.

3. Cohen AS, Matharu MS, Goadsby PJ. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) or cranial autonomic features (SUNA)—A prospective clinical study of SUNCT and SUNA. Brain 2006;129:2746–2760.

4. Silberstein SD, Vodovskaia N. Trigeminal autonomic cephalalgias other than cluster headache. Med Clin North Am 2013; 97:321–328.

5. Brown RS, Pass B. Orofacial pain due to trigeminal autonomic cephalgia with features of short-lasting neuralgiform headache attacks with conjunctival injection and tearing: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 114:e13–e19.

6. Headache Classification Committee of the International Headache (IHS). The International Classification of Headache Disorders, ed 3 (beta version). Cephalalgia 2013;33:629–808.

7. Black DF, Dodick D. Two cases of medically and surgically intractable SUNCT: A reason for caution and an argument for a central mechanism. Cephalalgia 2002;22:201–204.

8. Goadsby PJ, Cittadini E, Cohen AS. Trigeminal autonomic cephalalgias: Paroxysmal hemicrania, SUNCT/SUNA, and hemicrania continua. Semin Neurol 2010;30:186–191.

9. de Leeuw R, Klasser GD (eds). Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management, ed 5. Chicago: Quintessence, 2013:127–152.

10. Pareja JA, Joubert J, Sjaastad O. SUNCT syndrome. Atypical temporal patterns. Headache 1996;36:108–110.

11. Pareja JA, Sjaastad O. SUNCT syndrome. A clinical review. Headache 1997;37:195–202.

12. Pareja JA, Caminero AB, Sjaastad O. SUNCT syndrome: Diagnosis and treatment. CNS Drugs 2002;16:373–383.

13. Choi HJ, Choi SK, Lee SH, Lim YJ. Whiplash injury-induced atypical short-lasting unilateral neuralgiform headache with conjunctival injection and tearing syndrome treated by greater occipital nerve block. Clin J Pain 2012;28:342–343.

14. De Benedittis G. SUNCT syndrome associated with cavernous angioma of the brain stem. Cephalalgia 1996;16:503–506.

15. Chitsantikul P, Becker WJ. SUNCT, SUNA and pituitary tumors: Clinical characteristics and treatment. Cephalalgia 2013;33: 160–170.

16. Favoni V, Grimaldi D, Pierangeli G, Cortelli P, Cevoli S. SUNCT/SUNA and neurovascular compression: New cases and critical literature review. Cephalalgia 2013;33:1337–1348.

17. Jacob S, Saha A, Rajabally Y. Post-traumatic short-lasting unilateral headache with cranial autonomic symptoms (SUNA). Cephalalgia 2008;28:991–993.

18. Derogatis LR. SCL-90: Administration, Scoring and Procedures Manual-I for the R (evised) Version and Other Instruments of the Psychopathology Rating Scale Series. Baltimore: John Hopkins University, 1977.

19. Derogatis LR, Rickels K, Rock AF. The SCL-90 and the MMPI: A step in the validation of a new self-report scale. Br J Psychiat 1976;128:280–289.

20. Stein KD, Martin SC, Hann DM, Jacobsen PB. A multidimensional measure of fatigue for use with cancer patients. Cancer Pract 1998;6:143–152.

21. Diener E, Emmons RA, Larsen RJ, Griffin S. The Satisfaction With Life Scale. J Pers Assess 1985;49:71–75.

22. Pavot W, Diener E, Colvin CR, Sandvik E. Further validation of the Satisfaction with Life Scale: Evidence for the cross-method convergence of well-being measures. J Pers Assess 1991; 57:149–161.

23. Granato A, Belluzzo M, Fantini J, Zorzon M, Koscica N. SUNCT-like syndrome attributed to varicella-zoster virus meningoencephalitis. Neurol Sci 2015;36:807–808.

24. Cöven I, Coban G, Koyuncu G, Ilik KM. SUNCT syndrome findings accompanied by cavernous segment aneurysm. Clin Neurol Neurosurg 2013;115:781–783.

25. Musuka TD, Edis RH, Kermode AG. Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing caused by a pituitary adenoma. J Clin Neurosci 2013;20: 1180–1181.

26. Domingos J, Pereira PJ, Roriz MJ, Xavier AJ, Magalhães M, Monteiro PJ. Cavernous sinus dural fistula ‘mimicking’ SUNCT. Cephalalgia 2012;32:263–264.

27. Jiménez Caballero PE, Portilla Cuenca JC, Casado Naranjo

I. Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) secondary to epidermoid cyst in the right cerebellopontine angle successfully treated with surgery. J Headache Pain 2011;12:385–387.

28. Bogorad I, Blum S, Green M. A case of MS presenting with SUNCT status. Headache 2010;50:141–143.

29. Williams M, Bazina R, Tan L, Rice H, Broadley SA. Microvascular decompression of the trigeminal nerve in the treatment of SUNCT and SUNA. J Neurol Neurosurg Psychiatry 2010;81:992–996.

30. Ito Y, Yamamoto T, Ninomiya M, et al. Secondary SUNCT syndrome caused by viral meningitis. J Neurol 2009;256:667–668.

31. Bosco D, Labate A, Mungari P, Vero S, Fava A. SUNCT and high nocturnal prolactin levels: Some new unusual characteristics. J Headache Pain 2007;8:114–118.

32. Vilisaar J, Constantinescu CS. SUNCT in multiple sclerosis. Cephalalgia 2006;26:891–893.

33. de Siqueira SR, Nóbrega JC, Teixeira MJ, de Siqueira JT. SUNCT syndrome associated with temporomandibular disorders: Acase report. Cranio 2006;24:300–302.

34. Black D, Swanson J, Eross E, Cutrer FM. Secondary SUNCT due to intraorbital, metastatic bronchial carcinoid. Cephalalgia 2005;25:633–635.

35. Prakash KM, Lo YL. SUNCT syndrome in association with persistent Horner syndrome in a Chinese patient. Headache 2004;44:256–258.

36. Putzki N, Nirkko A, Diener HC. Trigeminal autonomic cephalalgias: A case of post-traumatic SUNCT syndrome? Cephalalgia 2005;25:395–397.

37. Moris G, Ribacoba R, Solar DN, Vidal JA. SUNCT syndrome and seborrheic dermatitis associated with craneosynostosis. Cephalalgia 2001;21:157–159.

38. Matharu MS, Levy MJ, Merry RT, Goadsby PJ. SUNCT syndrome secondary to prolactinoma. J Neurol Neurosurg Psychiatry 2003;74:1590–1592.

39. Zidverc-Trajkovic J, Mijajlovic M, Pavlovic AM, Jovanovic Z, Sternic N. Vertebral artery vascular loop in SUNCT and concomitant trigeminal neuralgia. Case report. Cephalalgia 2005; 25:554–557.

40. Kaphan E, Eusebio A, Donnet A, Witjas T, Ali Chérif A. Shortlasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing (SUNCT syndrome) and tumour of the cavernous sinus. Cephalalgia 2003;23:395–397.

41. Rinaldi F, Rao R, Venturelli E, et al. Where SUNCT contacts TN: A case report. Headache 2013;53:1492–1495.

42. Pareja JA, Barón M, Gili P, et al. Objective assessment of autonomic signs during triggered first division trigeminal neuralgia. Cephalalgia 2002;22:251–255.

43. Lambru G, Matharu MS. SUNCT, SUNA and trigeminal neuralgia: Different disorders or variants of the same disorder? Curr Opin Neurol 2014;27:325–331.

44. D’Andrea G, Granella F, Ghiotto N, Nappi G. Lamotrigine in the treatment of SUNCT syndrome. Neurology 2001;57: 1723–1725.

45. Malik K, Rizvi S, Vaillancourt PD. The SUNCT syndrome: Successfully treated with lamotrigine. Pain Med 2002;3: 167–168.

46. Piovesan EJ, Siow C, Kowacs PA, Werneck LC. Influence of lamotrigine over the SUNCT syndrome: One patient follow-up for two years. Arq Neuropsiquiatr 2003;61:691–694.

47. Rossi P, Cesarino F, Faroni J, Malpezzi MG, Sandrini G, Nappi

G. SUNCT syndrome successfully treated with topiramate: Case reports. Cephalalgia 2003;23:998–1000.

48. Etemadifar M, Maghzi AH, Ghasemi M, Chitsaz A, Kaji Esfahani M. Efficacy of gabapentin in the treatment of SUNCT syndrome. Cephalalgia 2008;28:1339–1342.

49. Marziniak M, Breyer R, Evers S. SUNCT syndrome successfully treated with the combination of oxcarbazepine and gabapentin. Pain Med 2009;10:1497–1500.

50. Ikawa M, Imai N, Manaka S. A case of SUNCT syndrome responsive to zonisamide. Cephalalgia 2011;31:501–503.

51. Taylor CP. Emerging perspectives on the mechanism of action of gabapentin. Neurology 1994;44(6, suppl 5):S10–S16.

52. Sills GJ. The mechanisms of action of gabapentin and pregabalin. Curr Opin Pharmacol 2006;6:108–113.

53. Rozen TD, Beams JL. A case of post-traumatic LASH syndrome responsive to indomethacin and melatonin (a man with a unique triad of indomethacin-responsive trigeminal autonomic cephalalgias). Cephalalgia 2015;35:453–456.

54. Hollingworth M, Young TM. Melatonin responsive hemicrania continua in which indomethacin was associated with contralateral headache. Headache 2014;54:916–919.

55. Tepper SJ, Stillman MJ. Cluster headache: Potential options for medically refractory patients (when all else fails). Headache 2013;53:1183–1190.