Temporal response to bupivacaine bilateral great occipital block in a patient with SUNCT syndrome

Short-lasting unilateral neuralgiform headache with con-junctival injection and tearing (SUNCT) syndrome is aninfrequent form of unilateral headache accompanied bycranial autonomic features [1]. The pain is severe, and thetitrations of some of the drugs have to be slow to preventside effects [2, 3]. We present a case of a patient withSUNCT syndrome who showed a temporal improvement ofpain with bupivacaine greater occipital nerve (GON) block.A 82-year-old woman was admitted because of recentonset of facial pain. Intense attacks of periocular left pain,lasting for 2 min, had started 3 days previously. She alsoexperienced conjunctival injection and lacrimation duringthe attacks. She suffered from 10 to 20 attacks per day. Theneurological examination was absolutely normal, exceptthat touching the left forehead triggered the pain withoutany refractory period. In the emergency room, with thesuspicion of trigeminal neuralgia, she was prescribed car-bamazepine 600 mg daily for a week, phenytoin 300 mgdaily for a week and tramadol 100 mg for 4 days, withoutany improvement. After a headache unit evaluation thediagnosis of SUNCT was made and we put the patient onlamotrigine and gabapentin with slow titration. Because thepatient was suffering from intense pain we decided toprove a bupivacaine GON block; she was asymptomatic for48 h. After 2 weeks she started with gabapentin 1,800 mgand lamotrigine 75 mg daily. The pain attacks improvedand in one more week she became asymptomatic.The response of SUNCT to intravenous lidocaine hasbeen described previously [4]. Intravenous lidocaine per-fusion carries risks, especially in the elderly [4]. GONblock has been used in several primary headaches, such asmigraine, cluster headache and hemicrania continua. Somestudies show that GON block could change trigeminalactivity [5]. GON block is a safe therapy and could be anoption for alleviation of SUNCT pain during oral drugstitration.