Short-lasting Unilateral Neuralgiform Headache Attacks with Conjunctival Injection and Tearing (SUNCT) sebagai Penyebab Nyeri Orbital Hebat pada Pasien Dewasa: Sebuah Laporan Kasus Komprehensif

Abstract

Introduction: Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) is an extremely rare trigeminal autonomic cephalalgia (TAC) characterized by highly frequent, ultra-brief, unilateral headache paroxysms accompanied by prominent ipsilateral cranial parasympathetic symptoms.¹ Diagnosing SUNCT is clinically challenging due to substantial overlap with trigeminal neuralgia and other TACs, requiring meticulous evaluation and neuroimaging to exclude secondary structural etiologies.¹

Case Illustration: A 47-year-old male presented with a 2-week history of excruciating, strictly right-sided orbital and supraorbital pain.⁴ The stabbing and burning paroxysms lasted 30-90 seconds, recurring 30-40 times daily, with an intensity of 9-10/10 on the Numeric Rating Scale (NRS).⁴ Attacks were triggered mechanically by touching the face, washing, or chewing, without any refractory period.⁴ Ipsilateral conjunctival injection, lakrimation, rhinorrhea, and marked psychomotor agitation consistently accompanied the pain.⁴ Neurological examination and non-contrast brain CT scan were normal.⁴ The patient was diagnosed with primary episodic SUNCT.⁴ A dual oral preventive therapy was immediately initiated with lamotrigine (25 mg/day, titrated up to 100 mg/day) and gabapentin (300 mg three times daily).⁴ At a 2-week follow-up, the daily attack frequency dramatically dropped to 5-7 times, and pain intensity significantly decreased to NRS 3-4/10, demonstrating excellent tolerability without adverse events.⁴

Discussion: SUNCT diagnosis relies on the ICHD-3 criteria.⁸ Pathophysiology involves central disinhibition of the trigemino-autonomic reflex and posterior hypothalamic activation.¹ Although lamotrigine is the gold-standard first-line preventive, its mandatory slow titration creates a critical therapeutic gap during acute, high-frequency phases.⁵ The early addition of gabapentin provided a rapid, synergistic antinociceptive effect through dual-channel blockade of sodium and calcium channels, achieving swift pain control without dose-limiting toxicities.¹²

Conclusion: Combining lamotrigine and gabapentin represents a highly effective, safe, and easily accessible oral regimen for immediate and sustained control of high-frequency episodic SUNCT in clinical practice.⁴