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What are the trigeminal autonomic cephalalgias (TACs)
TACs are a group of primary headache disorders characterized by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features.
TACs include CH, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA), and hemicrania continua.
Here is the table which provides a comparison of the clinical features of the shorter duration TACs.
These are typically diagnoses of exclusion with neuroimaging (preferably MRI scans including the pituitary) to exclude secondary causes.
Clinical Features of the Trigeminal Autonomic Cephalalgias
| Cluster Headache | Paroxysmal Hemicrania | SUNCT Syndrome | Hemicrania Continua | |
|---|---|---|---|---|
| Sex F:M | 1:3.5–7 | 2.13–2.36:1 | 1:2.1 | 2.4:1 |
| Pain | ||||
| Type | Stabbing, boring | Throbbing, boring, stabbing | Burning, stabbing, sharp | Background dull ache, throbbing/stabbing exacerbations |
| Severity | Excruciating | Excruciating | Severe | Moderate background pain; severe exacerbations |
| Site | Orbit, temple | Orbit, temple | Periorbital | Orbit, temple |
| Attack frequency | 1 every other day–8 daily | 1–40/day | 1/day–30/hr | Continuous |
| Duration of attack | 15–180 min | 2–45 min | 5–250 seconds | Continuous background pain; exacerbations quite variable and lasting minutes to days |
| Autonomic features | Yes | Yes | Yes (prominent conjunctival injection and lacrimation) | Yes—mainly with exacerbations; less prominent than with other TACs |
| Migrainous features ∗ | Yes | Yes | Yes † | Yes—during exacerbations |
| Alcohol trigger | Yes | Occasional | No | Rare |
| Indomethacin effect | – | ++ | − | ++ |
| Abortive treatment | Sumatriptan injection or nasal spray Oxygen | Nil | Nil | Nil |
| Prophylactic treatment | Verapamil Methysergide Lithium Prednisolone | Indomethacin | Lamotrigine Topiramate Gabapentin | Indomethacin |
TACs , Trigeminal autonomic cephalalgias.
∗ Nausea, photophobia, or phonophobia.
† Photophobia homolateral to pain.
Sources
From Goadsby PJ. Migraine and the trigeminal autonomic cephalagias. In: McMahon SB, Koltzenburg M, Tracey I, et al., editors. Wall & Melzack’s Textbook of Pain , 6th ed. Philadelphia: Elsevier; 2013. p. 815–831.
