Abstract
Trigeminal autonomic cephalalgias (TACs) are characterized by cranial autonomic symptoms (rhinorrhea, nasal congestion, conjunctival injection, lacrimation) accompanying unilateral headache attacks, comprising cluster headache, paroxysmal hemicrania, hemicrania continua, SUNCT, and SUNA. Attack duration is the key differentiating feature among these subtypes. For chronic cluster headache, the most effective abortive treatments are 100% oxygen inhalation via mask or subcutaneous/intranasal sumatriptan; preventive treatment favors verapamil first-line, with lithium, topiramate, or anti-CGRP monoclonal antibodies (galcanezumab) as alternatives. Neuromodulation techniques (vagal nerve, sphenopalatine ganglion, occipital nerve, and posterior hypothalamic stimulation) are reserved for medically refractory cases. For paroxysmal hemicrania and hemicrania continua, the key diagnostic feature is a complete response to indomethacin, which also serves as first-line preventive therapy; alternatives for intolerant patients include celecoxib, topiramate, and adjunctive melatonin. For SUNCT/SUNA, given the extremely short attack duration, preventive therapy predominates: intravenous lidocaine for short-term prevention, and topiramate/lamotrigine for long-term prevention. Microvascular decompression surgery shows high efficacy (78.7% good response) in patients with radiological evidence of neurovascular conflict. The review concludes that TACs, though rare, cause severe pain, and their rarity limits randomized controlled trial evidence. Pharmacological treatment remains first-line, with neuromodulation and surgical approaches considered for treatment-refractory cases.
