The role of lamotrigine in the treatment of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing syndrome.

To evaluate the efficacy of lamotrigine for treatment of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome. Literature was accessed through MEDLINE (1950-June 2010) using the terms lamotrigine, triazines, SUNCT, and trigeminal autonomic cephalgia. All articles in English and studies conducted in humans were identified and evaluated. SUNCT syndrome can be an extremely challenging headache type to manage and has been considered refractory to pharmacotherapy. Many anticonvulsants have been evaluated as promising SUNCT treatments, with lamotrigine specifically reported as an effective first-line treatment option. There is a lack of randomized placebo-controlled clinical trials evaluating lamotrigine in SUNCT syndrome therapy; however, 2 observational studies, 3 case series, and 5 case reports were reviewed. Lamotrigine appears to decrease the frequency and severity of SUNCT attacks, leading to complete resolution in some patients. A decrease in symptoms was achieved with doses ranging from 25 to 600 mg/day. In some cases, there was initial response to low doses, but dosage titrations were often necessary when symptoms returned several days after being managed at the same dose. Lamotrigine should be initiated at 25 mg/day and gradually titrated, guided by response and adverse effects. The risk of Stevens-Johnson syndrome, a dose-related adverse effect, can be minimized with gradual titration. According to case reports and observational studies, lamotrigine therapy has resulted in decreased frequency or resolution of SUNCT syndrome attacks. Randomized, controlled trials are necessary to confirm the efficacy of lamotrigine for this indication.