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A Nail in the Head: Short-lasting Unilateral Neuralgiform Headache Attacks

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An article with “short-lasting unilateral neuralgiform headache attacks” in the title isn’t necessarily going to catch your attention, but if you’ve experienced this type of headache, you know it’s not something that can be ignored.

Earlier this week we saw a video of Rev. David Wakefield, who has both chronic cluster headache and SUNCT, a form of the headache we’ll be talking about today. If you missed the video, see New Device Approved by FDA to Fight Cluster Headache (video).

SUNCT and SUNAWhat is officially called short-lasting unilateral neuralgiform headache attacks is actually one type of chronic daily headache. The headaches last only seconds or minutes (as long as ten minutes), but they are very painful and hit you at least once a day. The pain is on one side of the head, and the eye on that side will usually get red and watery.

As the title to this article implies, the pain is often described as “stabbing”, like a nail in the head.

With the red eye and tearing, the diagnosis is usually SUNCT, which stands for short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. That’s the version that Rev. Wakefield deals with.

If there is tearing (watery eye) or red eye, or neither, the diagnosis may be SUNA, or short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms. These headaches are accompanied by other symptoms that may occur in SUNA or SUNCT, such as congestion, facial sweating, and drooping or swelling or the eyelid.

Because of the congestion and tearing, SUNCT or SUNA may actually be misdiagnosed as sinus headache (more commonly, migraine is misdiagnosed as sinus headache – see Sinus Headache – Did You Really Beat It?).

Technically, the condition is considered “chronic” when it continues for a year or more, with less than a month pain-free.

Treatment of SUNCT and SUNA

There are some treatments that seem to help some people, but there have not been enough clinical trials to come up with consistent solutions (if they exist – treatment may be a very individual thing, especially until our understanding of the condition grows). Because the attacks are so brief, abortive treatment (stopping individual attacks) is not a major focus. Intravenous lidocaine or a phenytoin injection are sometimes used to try to stop a series of attacks.

To prevent attacks, medications such as lamotrigine, carbamazepine, gabapentin, and topiramate seem to help some patients, and nerve blocks may provide temporary relief.

Sometimes a certain cause is found for these symptoms, in which case treatment will vary. For example, compression of the trigeminal nerve or a structural lesion.

For more information, see:

Nortriptyline for Chronic Pain

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Nortriptyline, part of the class of drugs known as tricyclic antidepressants, is often used as a preventative to fight chronic pain.

Obviously, as an antidepressant, it’s commonly used to treat symptoms of depression.  It works in the chemicals of the brain by inhibiting the reuptake of norepinephrine (noradrenalin) and serotonin.  It’s commonly sold under the brand names Aventyl, Pamelor, Norpress, Allegron, Sensoval, and Nortrilen.

But nortriptyline hydrochloride (commonly misspelled as nortriptilyne) has long been used for a variety of other conditions.  Some commonly go along with migraine, such as irritable bowel syndrome, fibromyalgia, and TMJ disorder.  But it is also used to treat chronic pain, particularly the pain of migraine and tension-type headache, but also cancer pain and arthritic pain.

Sometimes nortriptyline is given along with gabapentin (Neurontin) for certain types of pain.  Gabapentin is an anti-convulsant, also prescribed for migraine prevention.

Many drugs in this class are very common in migraine treatment.  If your doctor prescribes one, it doesn’t mean that she thinks you’re depressed – though they may be used for migraine with depression as well.

Usually your doctor will start you on a low dosage, and raise it slowly.  As is common with migraine treatment, you may need to try it for three months before you can really tell if it works for you.  Side effects may diminish over time as well.

Important notes:

This is not likely to be the first drug your doctor will try.  Although it the side effects are usually mild, there are still more concerns with this type of drug than with other treatments.

First, be sure you’re working with a doctor who knows your medical history.  Nortriptyline can interact with some drugs, and make some more powerful, which can be dangerous.  Particular caution needs to be taken if you’ve used a MAO inhibitor drug in the past.  Also, if you have any history of seizures or heart conditions, your doctor will probably want to look elsewhere for treatment.

Your doctor will also want to monitor you carefully for the first while, particularly if you have any history of depression.  Younger patients (ie teens and young adults) have been known to experience suicidal thoughts early on in the treatment.

However, as I’ve said, side effects are usually mild.  These include sleepiness, confusion, dry mouth, constipation (particularly in older adults), and visual problems (including increased sensitivity to light).

Patients that stop taking nortriptyline for migraine often do so because it makes them sleepy.  But do discuss the side effects carefully with your doctor – they may diminish or change over time.

That being said, nortriptyline has helped many patients with chronic migraine and tension-type headache.  Other good news is that there’s not a high risk of dependence as with some other drugs, and you may be able to take a lower dosage if you’re not being treated for depression as well.

Key points to remember

If your doctor has prescribed nortriptyline, here are a few things to keep in mind:

  • This is a common treatment for migraine and chronic pain.
  • Be patient; give it three months before expecting a big change in your symptoms.
  • Be sure your specialist knows your medical history (particularly a history of heart problems or seizure), and knows about all the drugs and supplements you’re taking.
  • Talk to your doctor about the side effects you experience – even if they change over time.
  • Don’t change your dosage or stop taking the drug without talking to your doctor.
  • If it’s not effective, don’t give up – there are many other options!

More on nortriptyline from Drugs.com

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The articles on Headache and Migraine News are © 2004-2024 J. Cottrill.
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