Medical treatment of SUNCT and SUNA: a prospective open-label study including single-arm meta-analysis

J Neurol Neurosurg Psychiatry. 2021 Mar;92(3):233-241. doi: 10.1136/jnnp-2020-323999. Epub 2020 Dec 24.


Introduction: The management of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting 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.

Publication types

  • Comparative Study
  • Meta-Analysis

MeSH terms

  • Administration, Oral
  • Adolescent
  • Adult
  • Aged
  • Analgesics / therapeutic use*
  • Anesthetics, Local / therapeutic use*
  • Anticonvulsants / therapeutic use*
  • Female
  • Humans
  • Infusions, Parenteral
  • Male
  • Middle Aged
  • Prospective Studies
  • SUNCT Syndrome / complications
  • SUNCT Syndrome / diagnosis
  • SUNCT Syndrome / drug therapy*
  • Young Adult


  • Analgesics
  • Anesthetics, Local
  • Anticonvulsants