Clinical Significance of Response to Spinal Manipulation in Suspected SUNCT/SUNA
The dramatic response to spinal manipulation and ability to discontinue oxcarbazepine strongly suggests this was NOT primary SUNCT/SUNA, but rather a secondary or cervicogenic headache syndrome mimicking SUNCT/SUNA. True primary SUNCT and SUNA are highly refractory conditions that do not respond to mechanical interventions like chiropractic manipulation.
Why This Response Pattern Argues Against Primary SUNCT/SUNA
Primary SUNCT/SUNA are medical conditions requiring pharmacological management, with lamotrigine being the most effective preventive therapy and intravenous lidocaine the most efficacious transitional treatment for severe disabling attacks 1, 2, 3.
Oxcarbazepine is not a first-line or evidence-based treatment for SUNCT/SUNA, as the most effective medications are lamotrigine, topiramate, and gabapentin based on open-label trials and clinical experience 2, 4.
The complete resolution with spinal manipulation suggests a structural or cervicogenic etiology rather than the hypothalamic and trigeminal nerve dysfunction that characterizes true SUNCT/SUNA 4.
True SUNCT/SUNA patients typically require ongoing medical therapy and do not achieve sustained remission from mechanical interventions alone 1, 3.
What This Clinical Course Suggests Instead
Consider cervicogenic headache or occipital neuralgia that presented with autonomic features mimicking SUNCT/SUNA, as these conditions can respond dramatically to spinal manipulation and physical therapy.
Secondary SUNCT/SUNA from structural lesions (such as posterior fossa lesions, brainstem pathology, or neurovascular compression) should be reconsidered, though these typically require surgical intervention rather than chiropractic care 3.
The initial response to oxcarbazepine may have been coincidental or placebo effect, as this medication lacks robust evidence for SUNCT/SUNA and the natural history of the condition may have been self-limited.
Critical Diagnostic Reconsideration Needed
Revisit the original diagnosis by confirming whether the attacks truly met ICHD-3 criteria for SUNCT (conjunctival injection AND tearing required) or SUNA (only one cranial autonomic symptom) 2, 4.
Verify attack characteristics: True SUNCT/SUNA have side-locked unilateral pain with three attack patterns (single stabs, stab groups, or saw-tooth pattern), attack duration of seconds to minutes, and high attack frequency (often multiple attacks per day) 2, 4.
Confirm the presence of cutaneous triggering, which is common in SUNCT/SUNA (touching, chewing, eating being most frequent triggers), but this can also occur in trigeminal neuralgia and cervicogenic headache 2, 4.
Common Diagnostic Pitfall to Avoid
Do not assume all short-lasting unilateral headaches with autonomic features are SUNCT/SUNA, as cervicogenic headache, occipital neuralgia, and trigeminal neuralgia can all present with similar features but have fundamentally different treatment approaches and prognoses 3.
The lack of response to indomethacin is useful diagnostically to distinguish SUNCT/SUNA from paroxysmal hemicrania, but response to mechanical manipulation is NOT consistent with primary SUNCT/SUNA 4.
If this were true SUNCT/SUNA, expect recurrence once chiropractic care is discontinued, as these are chronic relapsing conditions requiring ongoing preventive medication 1, 2, 3.