Abstract
Dear Sir Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT syndrome) is a primary headache, marked by trigeminal pain in association with autonomic symptoms (1, 2). The pain is of short duration (5–250 s), stabbing or burning in quality, abrupt, frequent (one per day to 30 per hour) accompanied by lacrimation, nasal stiffness, rhinorrhea and conjunctival injection (2). Several types of drugs (carbamazepine, sumatriptan, prednisolone and non-steroidal anti-inflammatory drugs) have shown little benefit (1–3). Recently, Graff-Radford (4) reported a SUNCT patient who responds to gabapentin. We describe a woman with SUNCT who was treated successfully treated with this drug.
A 55-year-old woman presented with a 1-year history of headache. The pain was described as unilateral severe and throbbing located in the right retro-orbital area. The pain occurs in paroxysms lasting 60 s. The pain was accompanied by ipsilateral lacrimation of the eye, swelling of the brow, nasal stiffness and conjunctival injection. No phono- or photophobia or nausea was present. No precipitating mechanisms were identified. The frequency of attacks was three to four episodes per day. Clinical and neurological examination and MRI of the brain were normal. The patient had tried multiple medications without success, including daily non-steroidal anti-inflammatory drugs, serotonin re-uptake inhibitors and flunarizine.
Her mother and one sister suffered from migraine. Anamnesis was unremarkable except for glaucoma. Because of the glaucoma we decided not to attempt treatment with carbamazepine, and we decided to treat the patient with gabapentin 300 mg t.i.d. After 1 month the attacks were abolished. Three months later gabapentin was stopped without any recurrence of the pain.
SUNCT appears to be refractory to medical therapy. There are isolated cases reporting sumatriptan alleviation of SUNCT, but these probably reflect spontaneous attack remissions rather than drug-induced remissions.
Preventive agents that have been tried in SUNCT include paracetamol, aspirin, naproxen, indomethacin, prednisone, ergotamine, dihydroergotamine, methysergide, sumatriptan, verapamil, valproate, lithium, propranolol, amitriptyline, azathioprine, carbamazepine and lamotrigine (1–4). Only carbamazepine alone or in combination with corticosteroids, lamotrigine, gabapentin and percutaneous trigeminal ganglion compression have shown partial effect in some patients (3–7). Gabapentin (GBP), as well as carbamazepine and lamotrigine, is an antiepileptic drug used in the treatment of diabetic neuropathy pain, post-herpetic neuralgia and trigeminal neuralgia. GBP has demonstrated an analgesic effect for the treatment of neuropathic pain. Because GBP has a favourable side-effects profile, some authors consider GBP a first-line treatment for neuropathic pain. GBP mechanisms of action are still not thoroughly defined (8). These observations have to be confirmed with other cases. If so, we consider that GBP could be an option in treatment of patients with SUNCT syndrome.