Abstract

A number of therapeutic strategies have been tried for SUNCT with limited success, including medical management, nerve blockade and neurosurgical procedures.

A 74-year-old man was admitted with unilateral intense, short lived retro-orbital pain in association with conjunctival injection, rhinorrhea and prominent lacrimation. These brief attacks would last for seconds, but recurred with no refractory period. Neurological examination was unremarkable. Imaging was limited by the presence of a permanent pacemaker, however CT Brain did not demonstrate any abnormalities. His condition was felt to warrant urgent intervention owing to a very poor oral intake (related to his triggered attacks). Cardiological problems made intravenous lidocaine a high risk strategy. A trial of supra and infra-orbital nerve blockade produced immediate relief of pain, symptoms returned after the effects of the local anaesthetic had worn off. Radiofrequency ablation led to complete relief of the pain and the patient was able to resume oral nutrition. Various therapeutic strategies have been advocated for SUNCT. The larger case series recommend lamotrigine, gabapentin and topiramate, with intravenous lidocaine for short-term relief. Some benefit from greater occipital nerve blockade is reported, but results have been equivocal and surgical approaches have not shown consistent benefit. This is the first effective use of supra and infra-orbital nerve blockade that has been reported to our knowledge.