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Short-Lasting Primary Headaches
Primary Stabbing Headache – SUNCT and SUNA Syndromes
Primary stabbing headache or an “ice pick headache” is a short-lasting (seconds) strong stabbing pain, which is usually limited to the front of the head and the uppermost part of the face.
The attacks come either as a single jolt of pain, or they may run in series from a single one to multiple per day.
Primary stabbing headache is limited to a very small area of the scalp or the face. The site of pain is variable and is different from attack to attack. Stabbing pain in the same area over and over again is not typical for this pain syndrome; other disease has to be ruled out.
Ice pick headaches are common in migraineurs, cluster headache and hemicrania continua sufferers. Primary stabbing headaches may happen in any age group, children included.
Melatonin and Indomethacin appear to be effective but no controlled studies are available.
SUNCT Syndrome stands for Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing.
Headache Characteristics in SUNCT Syndrome
The attacks of unilateral, stubbing, burning, prickling, or electric shock-like pain are extremely short. The abrupt onset bout of pain reaches its maximum within 3 seconds, plateaus for a few seconds and quickly stops. Some patients experience rapid changing of pain intensity within each bout of pain in a “saw-tooth-like” pattern.
Pain is strictly unilateral and tends to stay on the same side. Bilateral pain in SUNCT syndrome is rare. Typically, pain is localized to the area around the orbit and may radiate to the check, nose, ear, temple, and palate. The epicenter of pain may be felt in the forehead, temple, or occasionally in any other part of the head. Pain localization outside the front of the head makes SUNCT diagnosis challenging. The only clue then is a unique pain quality, dynamics and pattern.
The intensity of pain is moderate-to-severe. The attacks last from 10 to 60 seconds. Some patients experience rapid change of pain intensity within short period of time.
Pain attacks tend to happen almost exclusively during the day. The attack frequency is variable – from occasional to 80 per day. Normally, there is no pain in between the attacks but some discomfort in the same area may be felt outside the bouts of typical pain.
SUNCT Syndrome Associated Symptoms and Triggers
SUNCT syndrome attacks are associated with conjunctival injection (prominence of the superficial blood vessels of the conjunctiva) and tearing on the side of pain. Runny nose and stuffed nostril on the same side may accompany the pain attacks in 67%. Eyelid swelling, redness of the face, and light sensitivity are rare.
Sometimes SUNCT syndrome-like headache pattern occurs without associated tearing and conjunctival injection. The term SUNA (Short-lasting Unilateral Neuralgiform headache-attacks with Autonomic symptoms) is used in those cases. SUNA is likely a SUNCT syndrome variant.
Many SUNCT/SUNA syndrome sufferers report triggers, such as chewing, nose blowing, coughing, squinting, forehead touching, neck movements or eating ice-cream.
SUNCT/SUNA Syndromes Diagnosis, Prognosis, and Treatment
SUNCT/SUNA syndrome is commonly incorrectly diagnosed as trigeminal neuralgia. Brain MRI is generally recommended for work up to rule out structural lesions responsible for the pain syndrome. SUNCT/SUNA syndrome remains a clinical diagnosis, meaning that no specific findings are expected on the diagnostic work up.
The typical age of onset is between 40 and 70 years. Incidence of this disorder is unknown. It appears to be slightly more common in males.
SUNCT is an episodic headache disorder. Pain periods may last from weeks to months with headache free periods from months to years.
More than 10 different agents have been tried for the headache prevention in SUNCT syndrome. Partial effectiveness was reported for steroids and Carbamazepine in some patients. Lamotrigine appears to be the most effective medication and some patients respond to Topamax and Gabapentin.