Trigeminal autonomic cephalalgias (TACs)

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Made up of

Cluster headache (CH)

Paroxysmal hemicrania (PH)

Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA)

Short-lasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)

Summary

Syndrome	Cluster headache	Paroxysmal hemicrania	SUNCT/SUNA	Hemicrania continua
Duration	- 15 min to 3 hr - Up to 8 attacks/day	- 2 to 30 min - Up to 40 attacks/day	- 5 sec to 4 min - Up to 200 attacks/day	- Continuous, with hour/day exacerbations - Remitting/unremitting
F:M	1:2.5–7.2	1:1	1:1.5	ㅤ
Pain type	Sharp, throbbing	Sharp, throbbing	Stabbing, burning	ㅤ
Pain severity	Very severe	Very severe	Very severe	ㅤ
Pain site	Orbit, temple	Orbit, temple	Orbit, temple	ㅤ
Clues to diagnosis	- Circadian/circannual timing - Evening occurrence - Male predominance	- Head turning as trigger - Indometacin response - Alcohol provocation	- Cutaneous stimulus as trigger (face touch) - Single/recurrent/sawtooth pain	- Foreign body feeling in affected eye (sand or eyelash sensation) - Indometacin response
Circadian periodicity	70%	45%	Absent	ㅤ
Autonomic features	Yes	Yes	Yes	ㅤ
Restless/agitated	90%	80%	65%	ㅤ
Migrainous features	Yes	Yes	Rare	ㅤ
Triggers: Alcohol	++	+	-	ㅤ
Triggers: Cutaneous	-	-	++	ㅤ
Indometacin effect	- (rarely +)	Absolute response	-	ㅤ
Acute treatment	- Oxygen - Triptans (subcutaneous/nasal)	No evidence (can consider triptans)	Intravenous lidocaine	No evidence (can consider triptans)
Preventive treatment	- Verapamil - Glucocorticoids - Galcanezumab - Lithium - Methysergide - Topiramate	Indometacin	- Lamotrigine - Gabapentin - Oxcarbazepine - Topiramate	Indometacin
Abortive treatment	- Sumatriptan - Sumatriptan or Zolmitriptan nasal spray - Oxygen	Nil	Nil	ㅤ
Transitional treatment	Corticosteroids, GONB	GONB	GONB, IV lidocaine	ㅤ

Differential diagnosis of facial pain (using the International Headache Society classification)

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HEENT indicates head, eyes, ears, nose, and throat

TMJ, temporomandibular joint

Differential diagnosis of short lasting headaches

Feature	Cluster headache	Paroxysmal hemicrania	SUNCT	Idiopathic stabbing headache	Trigeminal neuralgia	Hemicrania continua	Hypnic headache
Gender (M:F)	9:1	1:3	8:1	F>M	F>M	1:1.8	5:3
Pain type	Boring	Boring	Stabbing	Stabbing	Stabbing	Steady	Throbbing
Pain severity	Very	Very	Moderate	Severe	Very	Moderate	Moderate
Pain location	Orbital	Orbital	Orbital	Any	V2/V3 > V1	Unilateral	Generalised
Duration	15–180 mins	2–45 mins	15–120 sec	<5 sec	<1 sec	Continuous	15–30 mins
Frequency	1–8/day	1–40/day	1/day–30/hr	Any	Any	Variable	1–3/night
Autonomic	+	+	+	–	–	+	–
Alcohol	+	±	+	–	–	–	–
Indometacin	– (?)	+	–	+	–	+	Lithium

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Medical management

Drug	Dosage	Side effects
Carbamazepine	100–1200 mg/day	Impaired mental and motor function, death from hematological reaction, nausea, ataxia, diplopia
Baclofen	Initially 5 mg tid x 3 days, then increase 10–20 mg/day every 3 days to a maximum dose of 50–60 mg/day	Drowsiness, weakness, hypotension, constipation
Phenytoin	Initially 100 mg twice daily; can be increased to 800 mg/day	Lethargy, nystagmus
Lamotrigine	25 mg/day x 2 weeks, 25 mg bid x 2 weeks, maximum dose 50–100 mg twice daily	Headache, lethargy, nausea, tremor, insomnia
Clonazepam (if carbamazepine contraindicated)	4–8 mg/day	Drowsiness, ataxia
Pimozide	2–12 mg/day	Tremor, convulsions, hypersensitivity, sedation
Valproic acid	250–500 mg four times daily	Tremors, confusion, nausea, weight gain, hepatotoxicity
Sumatriptan (refractory cases)	50–100 mg/day	Nausea, vomiting
Oxycarbazapine	300 mg bid/day up to 1200 mg/day	Dizziness, diplopia, ataxia, nausea, somnolence, headache, hyponatremia
Gabapentin	300 mg 1st day, 2nd day 300 mg bid, 3rd day 300 mg tid and then maintain; can give up to 2400 mg/day	Somnolence, dizziness, tremor, ataxia, fatigue, nystagmus
Topiramate	50–150 mg/day	Dizziness, somnolence, weight loss

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