The Association Between Migraine, SUNCT and SUNA

Written by: Kylie Petrarca RN, BSN

Medically Reviewed by: Dr. Shivang Joshi

Edited by: Melissa Calise and Leigh Serth

What are SUNCT and SUNA?

SUNCT and SUNA are extremely rare headache diseases that are in the class of headache disorders known as Trigeminal Autonomic Cephalalgias. Trigeminal autonomic cephalgias, also known as TAC’s, are a group of headache disorders characterized by one sided head pain and cranial autonomic symptoms which may include a runny or stuffy nose, a sensation of fullness in the ear, facial sweating and flushing. Conditions classified as TAC’s include: Hemicrania Continua, Paroxysmal Hemicrania, Cluster Headache, SUNCT and SUNA. According to the International Headache Society Diagnostic criteria, to be diagnosed with SUNCT or SUNA a person must experience¹:

• At least 20 attacks that meet the criteria below 
• Moderate or severe unilateral head pain. Pain is typically located around one eye or near the temporal region of the head. Pain lasts for 1 second to 10 minutes and occurs as a single stab or series of stabs. Attacks may occur up to 200 times in one day.
• At least one of the following five cranial autonomic symptoms or signs must be present in addition to pain:
  • Eye tearing or redness
  • Nasal congestion or runny nose
  • Eyelid swelling
  • Forehead and facial sweating or flushing
  • Sensation of fullness in the ear
  • Miosis and/or ptosis
  • Occurring with a frequency of at least one a day
  • Not better accounted for by another ICHD-3 diagnosis

What do SUNCT and SUNA stand for? 

SUNCT stands for Short-lasting Unilateral Neuralgiform Conjunctival Injection and Tearing

• Short lasting- Typically lasts less than 10 minutes
• Unilateral – One sided
• Neuralgiform- Feels like nerve pain
• Conjunctival Injection – Red eyes
• Tearing- Generates tears from the eyes

SUNA stands for Short-lasting Unilateral Neuralgiform with Cranial Autonomic Symptoms

• Short lasting- Typically lasts less than 10 minutes
• Unilateral – One sided
• Neuralgiform- Feels like nerve pain
• Autonomic- Symptoms are involuntary

Although these conditions present similarly, the key difference is that a person with SUNCT must have both eye redness and tearing on the same side as the pain compared to SUNA which may have only one or neither symptom but will often have other cranial autonomic symptoms.

Episodic vs Chronic SUNCT/SUNA 

Episodic SUNCT/SUNA is when a person experiences periods of attacks anywhere from 7 days to 1 year separated by pain free periods that occur for 3 months or more. A person has chronic SUNCT/SUNA when they have a remission period shorter than 3 months or attacks for more than one year without a remission period.

SUNCT/SUNA as a Secondary Disorder

It is important to note that SUNCT can also be a secondary disorder and has been reported in case studies of viral meningitis, multiple sclerosis, meningioma and more. An MRI of the brain with and without contrast is needed prior to diagnosis to check for secondary causes such as pituitary lesions, compression of a nerve or lesions on the bottom of the skull.

What are the Similarities Between Migraine and SUNCT/SUNA?

• Likely involve pathophysiology of the trigeminovascular system
• Share comorbidities such as red ear syndrome, trigeminal neuralgia, cluster headache and traumatic brain injury
• Medication Adaptation Headache can occur in both conditions from over-reliance on acute medications
• Common triggers for both conditions include smoke, alcohol, exercise, weather and stress
• Migraine and SUNCT/SUNA share treatment options including lamotrigine, lidocaine, topiramate, carbamazepine and nerve blocks

SUNCT, SUNA and Migraine

In addition to head pain, typical migraine symptoms include photophobia, phonophobia, nausea and vomiting. A study of 43 SUNCT patients and 9 SUNA patients found 49% of SUNCT patients (21) and 67% of SUNA patients (6) had a personal or family history of migraine.² They also found that 4 SUNCT patients had a combination of nausea, photophobia and phonophobia.² Interestingly, all four of these SUNCT patients had a personal history of migraine or a family history of migraine in a first degree relative.²  Another study of 102 subjects with either SUNCT (65) or SUNA (37) found more than half the people in each group had a personal or family history of migraine and those patients were more likely to have photophobia or phonophobia, worsening of pain during attacks and pain between attacks but were not more likely to have nausea.³  The similarities in the characteristics between migraine, SUNCT and SUNA suggest they may affect the same pathways.  Although it is unclear how a history of migraine or a concurrent diagnosis relates to SUNCT or SUNA, there is clearly a connection between both conditions that needs further study.

Treatment of SUNCT/SUNA

Treatment is the same for both SUNCT and SUNA. A provider may try prescribing indomethacin to rule out paroxysmal hemicrania and hemicrania continua which may present similarly. Acute treatment is difficult due to the short nature of these attacks but intravenous lidocaine, an analgesic and anti-inflammatory drug, is typically the first-line treatment. This treatment can be dangerous in those with certain heart arrhythmias, liver disease and heart disease. In a study of 15 people with SUNCT, 100% found relief from attacks with intravenous lidocaine and of 9 people with SUNA, 88% had relief.³ For preventive treatment, lamotrigine is frequently used and was found to reduce frequency and/or severity in 62% of 29 SUNCT patients and 31% of 16 SUNA patients.³ Other treatments include: 

• Oxcarbazepine
• Carbamazepine
• Gabapentin 
• Topiramate 
• Greater occipital nerve blocks 
• Supraorbital nerve blocks
• Occipital nerve stimulation 
• Nerve decompression surgery
• Neurostimulation

What Type of Doctor Should I See for Migraine and SUNCT/SUNA?

A clinician with a headache specialty is preferred to treat migraine and other headache disorders. A primary care provider may also be involved to help manage these conditions.

A Note to Patients and Providers

SUNCT and SUNA are rare primary headache disorders that may not be easily recognizable for a neurologist to diagnose. It is important to keep a log of the frequency, duration and characteristics of your symptoms if you think you may be experiencing SUNCT or SUNA. This can be helpful for a doctor to accurately diagnose this condition. More research is needed in this area. If you are interested in contributing to research, consider enrolling in Ciitzen’s SUNCT/SUNA registry.

Allied Partner

Resources

1. Management of Trigeminal Neuropathies by the Facial Pain Association
2. Find A Support Group By the Facial Pain Association
3. Breaking Down Trigeminal Autonomic Cephalalgias by AMD
4. SUNCT/SUNA Facebook Support Group
5. Research Study at the University of Texas, Houston 
6. SUNCT/SUNA Registry by Ciitizen

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References

1. https://ichd-3.org/3-trigeminal-autonomic-cephalalgias/3-3-short-lasting-unilateral-neuralgiform-headache-attacks/
2. Anna S. Cohen, Manjit S. Matharu, Peter J. Goadsby, 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, Volume 129, Issue 10, October 2006, Pages 2746–2760, https://doi.org/10.1093/brain/awl202
3. Weng, H. Y., Cohen, A. S., Schankin, C., & Goadsby, P. J. (2018). Phenotypic and treatment outcome data on SUNCT and SUNA, including a randomised placebo-controlled trial. Cephalalgia : an international journal of headache, 38(9), 1554–1563. https://doi.org/10.1177/0333102417739304
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*The contents of this blog are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The writer does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.