Chapter 015. Headache (Part 18)

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Secondary (Symptomatic) SUNCT SUNCT can be seen with posterior fossa or pituitary lesions. All patients with SUNCT/SUNA should be evaluated with pituitary function tests and a brain MRI with pituitary views. SUNCT/SUNA: Treatment Abortive Therapy Therapy of acute attacks is not a useful concept in SUNCT/SUNA since the attacks are of such short duration. However, intravenous lidocaine, which arrests the symptoms, can be used in hospitalized patients. Preventive Therapy Long-term prevention to minimize disability and hospitalization is the goal of treatment. The most effective treatment for prevention is lamotrigine, 200–400 mg/d. Topiramate and gabapentin may also be effective. Carbamazepine, 400–500 mg/d, has been reported by...

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Chapter 015. Headache (Part 18) Secondary (Symptomatic) SUNCT SUNCT can be seen with posterior fossa or pituitary lesions. All patients with SUNCT/SUNA should be evaluated with pituitary function tests and a brain MRI with pituitary views. SUNCT/SUNA: Treatment Abortive Therapy Therapy of acute attacks is not a useful concept in SUNCT/SUNA since the attacks are of such short duration. However, intravenous lidocaine, which arrests the symptoms, can be used in hospitalized patients. Preventive Therapy
Long-term prevention to minimize disability and hospitalization is the goal of treatment. The most effective treatment for prevention is lamotrigine, 200–400 mg/d. Topiramate and gabapentin may also be effective. Carbamazepine, 400–500 mg/d, has been reported by patients to offer modest benefit. Surgical approaches such as microvascular decompression or destructive trigeminal procedures are seldom useful and often produce long-term complications. Greater occipital nerve injection has produced limited benefit in some patients. Mixed success with occipital nerve stimulation has been observed. Complete control with deep-brain stimulation of the posterior hypothalamic region was reported in a single patient. For intractable cases, short-term prevention with intravenous lidocaine can be effective. Chronic Daily Headache The broad diagnosis of chronic daily headache (CDH) can be applied when a patient experiences headache on 15 days or more per month. CDH is not a single entity; it encompasses a number of different headache syndromes, including chronic TTH as well as headache secondary to trauma, inflammation, infection, medication overuse, and other causes (Table 15-10). Population-based estimates
suggest that about 4% of adults have daily or near-daily headache. Daily headache may be primary or secondary, an important consideration in guiding management of this complaint. Table 15-10 Classification of Chronic Daily Headache Primary >4 h Daily
type headachea hemicrania as Giant cell arteritis Sarcoidosis Behçet's syndrome Hemicrania SUNCT/SUNA Chronic CNS continuaa infection New daily Hypnic headache Medication-overuse persistent headachea headachea a May be complicated by analgesic overuse. b Some patients may have headache > 4 h per day.
Note: SUNCT, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing; SUNA, short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms.