Short-Lasting Unilateral Neuralgiform Headache Attacks With Conjunctival Injection and Tearing (SUNCT) Across Two Decades: Longitudinal Characterization and Multimodal Management of a Refractory Case

Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing (SUNCT) is a rare and often refractory primary headache disorder marked by extreme therapeutic complexity. We present the case of a 21-year follow-up of a 45-year-old woman with a 31-year clinical history of severe periorbital pain, which began in adolescence and was associated with a neurovascular conflict involving the nervus intermedius. She was first evaluated at age 24 after being referred by a neurosurgeon due to severe, right-sided, unilateral periorbital pain, mainly affecting the V1 territory. Diagnostic workup showed a neurovascular conflict involving the nervus intermedius. Throughout evolution, autonomic symptoms such as tear production, conjunctival redness, and eyelid swelling have been observed. The clinical course demonstrated prominent autonomic symptoms and resistance to multiple pharmacological and surgical interventions, with partial relief achieved only through a multimodal regimen of gabapentin, clonazepam, and indomethacin. This case illustrates the chronic nature of the pathology and emphasizes the importance of long-term longitudinal follow-up and multidisciplinary management in treatment-resistant presentations.