Short-Lasting Unilateral Neuralgiform Headache Attacks with Cranial Autonomic Symptoms (SUNA)

This case report presents a 38-year-old woman who presented with worsening of a preexisting facial pain. The pain was described as severe, stabbing sensations occurring in a sawtooth pattern, involving the distribution of the ophthalmic and maxillary branches of the trigeminal nerve on the left side, accompanied by grittiness in the left eye, congestion in the left nostril, and left aural fullness. Attacks last between 30 s and 2 min and occur from several to up to a hundred times daily with no refractory period between the attacks. Neurological examination was unremarkable. Brain magnetic resonance imaging (MRI) revealed a loop of the left superior cerebellar artery close to the left trigeminal nerve but without signal abnormalities in the root entry zone. Considering the lack of refractory period and the presence of ipsilateral cranial autonomic symptoms, she was diagnosed with short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) and started on treatment with intravenous lidocaine and subsequently oral lamotrigine, to which she responded well. SUNA is a rare primary headache disorder classified under trigeminal autonomic cephalalgias (TACs). It has a challenging presentation and is often misdiagnosed, negatively impacting the quality of life of the sufferers. In this chapter, we provide a comprehensive clinical overview of SUNA, aiming to enhance the identification of this condition and offer strategies for its management.