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Meta-Analysis
. 2021 Mar;92(3):233-241.
doi: 10.1136/jnnp-2020-323999. Epub 2020 Dec 24.

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

Giorgio Lambru  1 , Anker Stubberud  2   3 , Khadija Rantell  4 , Susie Lagrata  1   5 , Erling Tronvik  2   3 , Manjit Singh Matharu  6   5
Affiliations
Meta-Analysis

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

Giorgio Lambru et al. J Neurol Neurosurg Psychiatry. 2021 Mar.

Abstract

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.

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Conflict of interest statement

Competing interests: GL has received speaker honoraria, funding for travel and has received honoraria for participation in advisory boards sponsored by Allergan, Novartis, Eli Lilly and TEVA. He has received speaker honoraria, funding for travel from electroCore, Nevro Corp. and Autonomic Technologies. AS is cofounder of Nordic Brain Tech, a company developing a non-pharmacological biofeedback treatment for migraine and holds a pending patent application relating to the company’s product. KR has nothing to declare. SL has received payment for attending advisory meetings and development of presentation from Allergan Novartis, Eli Lilly and TEVA. ET: is a cofounder and shareholder of Nordic Brain Tech AS and Palion Medical AS. He serves on advisory board for Eli Lilly and Novartis and TEVA. He has received speaker honoraria from Eli Lilly, Novartis, Allergan and TEVA. MSM serves on the advisory board for Abbott, Allergan, Eli Lilly, Medtronic, Novartis, TEVA; has received payment for the development of educational presentations from Allergan, electroCore, Eli Lilly, Medtronic, Novartis, and TEVA; and, has received research grants from Abbott, electroCore and Medtronic.

Figures

Figure 1
Figure 1
Responder and discontinuation rates secondary to adverse effects for oral medical treatments in SUNCT and SUNA. SUNCT: Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injections and Tearing; SUNA: Short-lasting Unilateral Neuralgiform headache attacks with autonomic symptoms. * Mexiletine and lacosamide data were not included due to small sample size.
Figure 2
Figure 2
Forest plot of percentage of responders to lamotrigine in SUNCT and SUNA. SUNCT short-lasting unilateral neuralgiform attacks with conjunctival injection and tearing (SUNCT) and SUNA short-lasting unilateral neuralgiform headache attacks with autonomic symptoms (SUNA); CI = confidence interval.
Figure 3
Figure 3
Pooled weighted responder proportions with 95% CIs for all drugs analysed. SUNA, short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms; GONB: greater occipital nerve block; SUNCT, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing.
See this image and copyright information in PMC

References

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