Neurology — UKMLA MCQ

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A patient has 30 to 40 daily attacks of unilateral orbital pain lasting 20 to 60 seconds, each accompanied by conjunctival injection and tearing. MRI has excluded a secondary cause. Which oral preventive is the treatment of choice?

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Correct answer: A — Lamotrigine

The best answer is “Lamotrigine”. The very brief, high-frequency unilateral attacks with prominent ipsilateral autonomic features identify SUNCT, within the SUNCT/SUNA spectrum. The largest prospective treatment series supports lamotrigine as the oral preventive treatment of choice. Indometacin responsiveness instead points toward paroxysmal hemicrania, verapamil is the principal preventive for cluster headache, and propranolol or candesartan are migraine preventives. Secondary causes, particularly pituitary and posterior-fossa pathology, should be assessed before treating a presumed primary syndrome.

Reference: Medical treatment of SUNCT and SUNA: https://pmc.ncbi.nlm.nih.gov/articles/PMC7892380/