Diagnosing the trigeminal autonomic cephalalgias

Learn to diagnose the trigeminal autonomic cephalagias—paroxysmal hemicrania, hemicrania continua, and SUNCT.
Last update28th Feb 2021

We’ve already looked at cluster headaches, but there are three other trigeminal autonomic cephalalgias you should be familiar with:

  1. Paroxysmal hemicrania
  2. Hemicrania continua
  3. Short-lasting unilateral neuralgiform headaches with conjunctival injection and tearing (SUNCT)

Similar to cluster headaches, all of the trigeminal autonomic cephalalgias involve moderate to severe unilateral pain of the head or face and have features of autonomic nervous system activation.

Paroxysmal hemicrania

Paroxysmal hemicrania affect females more than males (2:1) and is characterized by frequent, severe, unilateral head pain, usually in the ocular, temporal, and maxillary regions. The pain may also radiate behind the eye and / or into the shoulder and arm on the ipsilateral side. The pain is usually described as boring, throbbing, or stabbing.

Figure 1. The characteristics of pain in paroxysmal hemicrania.

In this headache type, patients may also have trigeminal autonomic symptoms:

  • Conjunctival injection
  • Nasal congestion
  • Periorbital edema
  • Miosis and / or ptosis (not necessary for diagnosis)
  • Agitation or restlessness
Figure 2. Trigeminal autonomic symptoms may be seen in paroxysmal hemicrania.

There will be from 1 to 40 events daily, which may last from 2 to 120 minutes each, and these pain cycles occur in sudden attacks, which can last from one week to a year. Similar to cluster headaches, this syndrome has both episodic and chronic forms.

There are remissions in this disorder, but therapies for cluster headaches have no effect on paroxysmal hemicrania. However, paroxysmal hemicrania is responsive to indomethacin. Other nonsteroidal anti-inflammatory drugs are not effective for these headaches.

Hemicrania continua

Hemicrania continua headaches are unilateral, continuous, and have a mild to moderate intensity. There is a female predominance at a 2:1 ratio. Pain is generally not as severe as other headache types in this group. The pain is described as dull, aching, or pressure. It is ocular, temporal and / or maxillary in location. Events may last for 20 minutes.

Figure 3. The characteristics of pain in hemicrania continua.

Like with other trigeminal autonomic cephalalgias there are autonomic phenomena you should watch for:

  • Ipsilateral lacrimation
  • Ptosis
  • Conjunctival injection
  • Nasal congestion
Figure 4. Trigeminal autonomic symptoms may be seen in hemicrania continua.

Similar to paroxysmal hemicrania, hemicrania continua can be treated with indomethacin.

Short-lasting unilateral neuralgiform headaches with conjunctival injection and tearing (SUNCT)

These headaches are the rarest of the trigeminal autonomic cephalalgias. The pain often affects the region innervated by the ophthalmic division of the trigeminal nerve, but may also occur with radiation into the forehead, temple, nose, cheek, palate, and even the periauricular region and the occiput.

The pain is pricking, piercing, burning, stabbing, or shock-like.

Figure 5. The pain characteristics of short-lasting unilateral neuralgiform headaches with conjunctival injection and tearing (SUNCT).

Although not present in all patients with SUNCT, there are four associated trigeminal autonomic dysfunctions you should be aware of:

  • Ipsilateral conjunctival injection
  • Lacrimation
  • Nasal congestion
  • Periorbital edema

The headaches are very brief: pain maximizes very rapidly (in seconds), lasts for 5 to 250 seconds, and recurs multiple times a day.

Symptomatic periods last several days to months, with pain occurring once to 80 times a day, with an average of 30 episodes a day. Many patients say they have a dull pain between episodes.

The cycling of pain paroxysms with remissions is erratic in this disorder.

SUNCT can be episodic, with recurrences over seven days to a year but with pain free periods of at least three months. It is considered to be chronic when remissions last less than three months.

Since the individual episodes of pain are short-lived, treatment is usually focused on prevention. Drugs used include anticonvulsants such as lamotrigine, topiramate, gabapentin, and carbamazepine. Intravenous therapy (IV) lidocaine can abort a severe, frequently occurring event.

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Recommended reading

  • Burish, M. 2018. Cluster headache and other trigeminal autonomic cephalalgias. Continuum (Minneap Minn). 24: 1137–1155. PMID: 30074553
  • Ferguson, LW and Gerwin, R. 2005. Clinical Mastery in the Treatment of Myofascial Pain. Baltimore: Lippincott Williams & Wilkins.
  • Goadsby, PJ. 2012. Trigeminal autonomic cephalalgias. Continuum (Minneap Minn). 18: 883–895. PMID: 22868548
  • Goadsby, PJ and Silberstein, SD. 1997. Headache. Vol 17 of Blue books of practical neurology. Boston: Butterworth-Heinemann.
  • Goadsby, PJ, Silberstein, SD, and Dodick, DW. 2005. Chronic Daily Headache for Clinicians. Hamilton: BC Decker.
  • Rizzoli, P and Mullally, WJ. 2018. Headache. Am J Med. 131: 17–24. PMID: 28939471
  • Silberstein, SD, Lipton, RB, and Goadsby, PJ. 2002. Headache in Clinical Practice. 2nd edition. London: Martin Dunitz.

About the author

Robert Coni, DO EdS
Robert is Neurohospitalist, Medical Director, and Coordinator at the Grand Strand Medical Center, and Clinical Assistant Professor at the University of South Carolina.
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