Exacerbation of SUNCT and SUNA syndromes during intravenous dihydroergotamine treatment: A case series

Cephalalgia. 2015 Oct;35(12):1115-24. doi: 10.1177/0333102415570495. Epub 2015 Feb 9.


Background: The management of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and with short-lasting unilateral neuralgiform headache attacks with autonomic symptoms (SUNA) remains challenging in view of the limited understanding of their pathophysiological mechanisms.

Methods: An initial observation that patients with both chronic migraine (CM) or cluster headache (CH) and SUNCT/SUNA receiving intravenous dihydroergotamine (IV DHE) had complained of dramatic worsening of the latter led to review of the case notes of patients with CM or CH and co-existent SUNCT/SUNA seen between 2008 and 2013 and who had a trial of IV DHE.

Results: Twenty-four patients were identified. IV DHE was ineffective for SUNCT/SUNA in 16 patients, while one patient reported a marginal improvement. Five patients reported dramatic worsening of the SUNCT/SUNA. Moreover, two patients developed new-onset SUNA during their first IV DHE infusion. Out of these seven patients, those requiring repeated courses of IV DHE consistently experienced exacerbations of SUNCT/SUNA which were suppressed with IV lidocaine.

Conclusions: DHE is an ineffective treatment option for SUNCT and SUNA. Physicians who intend to offer IV DHE to CH or CM patients should warn them that IV DHE could exacerbate and possibly even lead to a de novo onset of SUNCT/SUNA. In view of the reported worsening or new onset of SUNCT/SUNA in patients using dopamine agonists for the treatment of pituitary prolactinomas, we speculate that DHE might worsen or induce SUNCT and SUNA, at least in a sub-group of patients, through a perturbation in the dopaminergic system.

Keywords: SUNA; SUNCT; chronic migraine; cluster headache; dihydroergotamine; trigemino-autonomic cephalalgias.

Publication types

  • Case Reports

MeSH terms

  • Adult
  • Analgesics, Non-Narcotic / administration & dosage
  • Analgesics, Non-Narcotic / adverse effects
  • Autonomic Nervous System Diseases / chemically induced*
  • Autonomic Nervous System Diseases / drug therapy*
  • Dihydroergotamine / administration & dosage*
  • Dihydroergotamine / adverse effects*
  • Female
  • Humans
  • Injections, Intravenous
  • Male
  • Middle Aged
  • Pain Measurement / drug effects
  • SUNCT Syndrome / chemically induced*
  • SUNCT Syndrome / diagnosis
  • SUNCT Syndrome / drug therapy*
  • Treatment Failure
  • Vasoconstrictor Agents / administration & dosage
  • Vasoconstrictor Agents / adverse effects


  • Analgesics, Non-Narcotic
  • Vasoconstrictor Agents
  • Dihydroergotamine