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Short-lasting unilateral neuralgiform headache attacks (SUNCT/SUNA): a narrative review of interventional therapies
  1. Rupert D Smit1,
  2. Nikolaos Mouchtouris1,
  3. KiChang Kang2,
  4. Maikerly Reyes2,
  5. Anish Sathe2,
  6. Sarah Collopy1,
  7. Giyarpuram Prashant1,
  8. Hsiangkuo Yuan3,
  9. James J Evans1
  1. 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
  2. 2Sidney Kimmel Medical School, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  3. 3Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Rupert D Smit, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA 19107, USA; rds116{at}


Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache with autonomic symptoms (SUNA) are disabling primary headache disorders. The advent of advanced imaging technologies and surgical techniques has translated to a growing arsenal of interventional therapies capable of treating headache disorders. This literature review sheds light on the current evidence available for interventional therapies in medically intractable SUNCT/SUNA. PubMed and EMBASE were searched for publications between 1978 and 2022. Inclusion criteria were SUNCT/SUNA studies reporting outcomes following occipital nerve stimulation (ONS), pulsed radiofrequency (PRF) of sphenopalatine ganglion (SPG), stereotactic radiosurgery (SRS), deep brain stimulation (DBS) or microvascular decompression (MVD) of the trigeminal nerve. A greater than 50% reduction in severity or a greater than 50% reduction in the number of attacks was defined as a successful response. The rate of successful responses for the various treatment modalities were as follows: ONS 33/41 (80.5%), PRF of SPG 5/9 (55.6%), DBS of the ventral tegmental area 14/16 (86.7%), SRS to the SPG and/or trigeminal nerve 7/9 (77.8%) and MVD 56/73 (76.7%). Mean follow-up time in months was 42.5 (ONS), 24.8 (PRF), 25.3 (DBS), 20.8 (SRS) and 42.4 (MVD). A significant proportion of SUNCT/SUNA patients remain refractory to medical therapy (45%–55%). This review discusses existing literature on interventional approaches, including neuromodulation, radiofrequency ablation, gamma knife radiosurgery and MVD. The outcomes are promising, yet limited data exist, underscoring the need for further research to develop a robust surgical management algorithm.

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  • Twitter @rd_smitMD, @TJUHNeurosurg, @MaikerlyR

  • Contributors RDS, NM, GP, JJE KK, MR wrote main drafts; RDS, NM, GP and HY reviewed and edited; KK created illustrations; AS and SC formatted tables and data collection.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Provenance and peer review Not commissioned; externally peer reviewed.