LETTERS TO THE EDITOR
|Year : 2019 | Volume
| Issue : 2 | Page : 249-250
Comments on “Short-lasting, unilateral, neuralgiform headache attacks”
Ottar Sjaastad1, Torbjorn Fredriksen2
1 Department of Neurology and Clinical Neurophysiology, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
2 Department of Neurosurgery, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
|Date of Web Publication||9-Apr-2019|
Prof. Ottar Sjaastad
Gautes Gate 12, 7030 Trondheim
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sjaastad O, Fredriksen T. Comments on “Short-lasting, unilateral, neuralgiform headache attacks”. Ann Indian Acad Neurol 2019;22:249-50
We have a few comments to some statements in a recent article in your journal, largely dealing with SUNCT. SUNCT was originally described by our group. It is an acronym: “Shortlasting, Unilateral, Neuralgiform Headache Attacks with Conjunctival Injection, Tearing, Sweating, and Rhinorrhea.”
Comment I: The authors  do not cite the acronym  correctly, in that they have left out the three last words of the title: “-sweating, and rhinorrhea” (two first lines, “Introduction”). In that way, the readers' insight into the full breadth of the autonomic involvement in SUNCT is hindered. This involvement does not only consist of conjunctival injection and tearing but also of forehead sweating and rhinorrhea and, besides, a multitude of other autonomic abnormalities. These facts are essential for the understanding of SUNCT and for the understanding of the disagreement between the authors and the commentators. The same misinformation is found several times later in the article. This tends to show that we are not faced with a casual mishap, but with a systematic trend.
We certainly hope that similar citation blunders will not happen again.
Comment II: SUNCT is characterized by unilateral, short-lasting spikes of pain in the ocular/periocular area. A perhaps even more characteristic trait of SUNCT is the coexistence of ipsilateral, cranial autonomic disturbances. They are invariably/close-to-invariably present. The ocular pulse amplitudes start increasing a couple seconds prior to the pain during attack, and the amplitude increase outlasts the pain by a couple seconds. This observation contributes to emphasizing the importance of the autonomic aberration in SUNCT. The amplitude increase does not seem to be secondary to the pain – it may even be vice versa. SUNCT with this unique, almost diagnostic combination, must not be linked with headache disorders having minimal autonomic disturbances.
Short-lasting unilateral neuralgiform headache attacks [SUNA] with cranial autonomic symptoms [e.g., 1] is a more recent invention. The inventors try to link it with SUNCT. SUNA is, if anything, rare. In a recent review, there were about six times as many SUNCT as SUNA cases.
In this situation, the present authors come up with a proposal: In this situation, the present authors  come up with a proposal for a superstructure, even with a new confusing abbreviation, that is, SUNHA, which should comprise many (all?) short-lasting, unilateral headaches, including trigeminal neuralgia (TN). It is stated that the clinical picture of SUNCT is rather similar to that of TN. Indeed, duration of pain attacks of SUNCT and TN may overlap. But, and this is tremendously important – the autonomic involvement differs vastly. The pure number of solitary autonomic phenomena, that is, conjunctival injection, lacrimation, and rhinorrhea, was counted in two adequately large series of TN, first branch, and SUNCT. In SUNCT, autonomic phenomena were much more prevalent than in TN (P < 0.0000005; Chi-square test). And, when present, such phenomena are much more profuse in SUNCT. Although the last variables have not been quantified, this difference is obvious, with massive abnormalities in SUNCT, and mostly hardly noticeable abnormalities in TN: This difference in appearance tells about the fundamental differences in underlying mechanisms. The main trait of SUNCT is probably the autonomic aberrations. It can probably be stated as firmly as this: Without these autonomic abnormalities: No SUNCT. SUNCT can thus not, just like that, be lumped with any short-lasting, unilateral headache.
Moreover, in SUNCT, there is a poor effect of carbamazepine and oxcarbazepine, whereas in TN there is an excellent effect. Nocturnal attacks are more frequent in TN than in SUNCT. Sex preponderance differs clearly in the two disorders. These are all significant differences. Trying to lump SUNCT, which is characterized by heavy autonomic involvement with TN that is “rarely associated with autonomic features,” is not a good idea. Attempts to link SUNCT with TH should be discontinued. Immediately and before damage is done.
Comment III: SUNCT is a rare disorder. Exactly how rare it is, is not known.
But we know something. In a big population study of headache epidemiology from Vågå community, Norway, 1838, or 88.6%, of 18–65-year-old inhabitants were personally examined by one of the present authors (OS). In Vågå, there were no cases of SUNCT. There were accordingly <1/1838 individuals in Vågå. The given figures are the only ones available as regards SUNCT prevalence. Surprisingly, the authors state that in the Vågå study, there were “two patients” with SUNCT. This is a wrong citation. In Vågå, there were two cases of a “SUNCT-like headache.” There were some traits, reminiscent of SUNCT in these individuals, but not enough to fulfill the diagnostic requirements. Just to mention a few points: The combination conjunctival injection/tearing was, for example, lacking. Nor could attacks be precipitated mechanically. Prevalence figures should not be based upon data encumbered with such uncertainty.
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