SUNCT Syndrome MCQ — NEET PG Practice Question | NEETPGAI
SUNCT Syndrome
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stethoscope Medicine
A 45-year-old man presents with recurrent episodes of severe, stabbing pain in the right orbit and supraorbital region lasting 30–90 seconds, occurring 5–15 times daily. Each attack is accompanied by ipsilateral conjunctival injection and tearing. Between attacks, the patient is completely pain-free with no refractory period. Brain MRI with pituitary protocol is normal. The condition marked **A** in the diagram is suspected. Which of the following is the MOST appropriate first-line preventive agent for this condition?
A. Lamotrigine, titrated slowly to 100–300 mg/day
B. Indomethacin 75–150 mg/day
C. Topiramate 100 mg/day as monotherapy
D. Oxygen inhalation during acute attacks
Explanation
Why Lamotrigine is correct
The condition marked A is SUNCT syndrome (Short-lasting Unilateral Neuralgiform headache with Conjunctival injection and Tearing), a rare trigeminal autonomic cephalalgia defined by very brief attacks (typically 10–120 seconds) of severe unilateral pain in the V1 distribution with mandatory ipsilateral conjunctival injection AND lacrimation. According to ICHD-3 and Continuum (Headache) 2018, lamotrigine is the mainstay of preventive treatment, titrated slowly to 100–300 mg/day to minimize rash risk. The clinical presentation—brief duration, high frequency (5–15/day), absence of refractory period, and bilateral autonomic features—is pathognomonic for SUNCT, and the normal MRI excludes secondary causes such as pituitary adenoma or posterior fossa lesions.
Why each distractor is wrong
Indomethacin 75–150 mg/day: Indomethacin is the defining treatment for hemicrania continua (option D), not SUNCT. This is a critical differential; SUNCT does NOT respond to indomethacin, whereas hemicrania continua is defined by absolute responsiveness to indomethacin. Confusing these two TACs is a common pitfall.
Oxygen inhalation during acute attacks: Oxygen is effective for acute cluster headache attacks (option B), not SUNCT. Moreover, SUNCT attacks are too brief (10–120 seconds) for abortive therapy to be practical. Oxygen is ineffective in SUNCT.
Topiramate 100 mg/day as monotherapy: While topiramate is listed as an alternative preventive agent for SUNCT, it is NOT first-line. Lamotrigine is preferred as the initial agent. Topiramate may be used if lamotrigine is ineffective or poorly tolerated, but it is not the mainstay.
High-YieldNEET PG
SUNCT = very brief attacks (10–120 sec), high frequency (3–200/day), mandatory BOTH conjunctival injection AND tearing, no refractory period, lamotrigine first-line, indomethacin does NOT work (that's hemicrania continua).
ICHD-3; Continuum (Headache) 2018
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