short - lasting unilateral neuralgiform headache with conjunctival injection and tearing ( sunct ) syndrome is an uncommon form of trigeminal autonomic cephalalgia ( tac ) . diagnostic criteria for sunct syndrome require at least 20 attacks of unilateral orbital , supraorbital or temporal stabbing or pulsating pain lasting 5240  s and occurring with a frequency from 3 to 200 per day . probable sunct is the syndrome with attacks fulfilling all but one of the criteria for sunct . several cases of secondary sunct syndrome , especially in patients with prolactinomas and growth - hormone secreting tumors , have been reported . although sunct syndrome is uncommon and its true frequency is unclear , its presence in nearly 5% of patients in the cohort with headache and pituitary tumors suggests that this syndrome may be over - represented in pituitary disease . according to the existing results , lamotrigine is the treatment of choice in sunct , followed by topiramate and gabapentin as proposed by efns task force . we have reported the case of headache fulfilling all diagnostic criteria for sunct syndrome except the criterion of unilateral presentation , associated with microprolactinoma and highly responsive to lamotrigine . we report a case of a 24-year - old right - handed female presented with a 6-year history of headaches in march 2006 . a typical attack was bilateral with pain affecting both sides simultaneously . the pain with an electric shock - like quality was centered on the retro - orbital region and temple with radiation to the occipital regions . the attacks had high pain intensity , estimated by the patient as 910 on a verbal analogue scale ( 010 ) , lasting 30  s and was associated with prominent conjunctival injection , lacrimation and periorbital face flushing that occurred five to ten times a day , and attacks of moderate pain , estimated as 6 on the same scale that lasted 56  s and occurred every 1520  min . she had attacks only when awake , with the first starting an hour after awaking , and was completely pain free during sleep . head movements , talking , eating , and blowing nose or other manipulations could not trigger the attacks . the patient had previously tried aspirin , diclofenac , paracetamol / caffeine combinations , amitriptyline 75  mg daily , sodium valproate 1,000  mg daily , all of which were ineffective . carbamazepine 800  mg daily reduced the frequency of milder attacks for about 30% and had no effect on attacks of higher intensity . the observations revealed that the conjunctival injection , lacrimation and face flushing were more prominent during more severe attacks . in spite of the patient s statement that pain is simultaneous and had equal intensity on both sides , we have observed that the autonomic features were more prominent on the right side . a trial of high - dose oxygen inhalation at flow rate 15  l / min and subcutaneous sumatriptan 6  mg had no effect . indomethacin administered in three doses of 25  mg per day was ineffective , as well as further dose increment that stopped at daily dose of 125  mg because of constant dull headache . according to ihcd - ii criteria lamotrigine was started at a dose of 25  mg once daily and the dose was increased to 100  mg twice daily over 6  weeks . during the first month on lamotrigine 200  mg daily the sunct attacks trials of dose reducing led to attacks recurrence . in spite of the fact that neurological examination was normal and that the headaches resolved completely with lamotrigine therapy , the bilaterality of patient s headache instantly raised the concern about possible symptomatic origin . according to the literature data about frequent association of sunct - like headache and pituitary tumors [ 2 , 58 ] and recommendations of the serbian headache guideline   that  mri examination should be performed on all patients with tacs because of relative rareness of the disorders with high frequency of secondary cases  , mri scan of pituitary  hypothalamic region was performed . magnetic resonance imaging revealed the pituitary microadenoma at the right side of the gland without extending towards the surrounding structures ( fig .  1 ) . the examination of pituitary hormones showed that serum prolactin levels were 2,125  mlu / l ( normal range 130700 ) , while the levels of follicle - stimulating hormone , luteinizing hormone , oestradiol , adrenocorticotropin hormone , basal cortisol , thyroid - stimulating hormone , free thyroxin , insulin , and growth factor were within normal range , so multiple endocrine neoplasm was ruled out . after 2  months of bromocriptine therapy serum prolactin levels were 574  mlu / l and cycle was ovulatory ( progesterone level was 27  nmol / l on the 21st day of cycle ) . however , on bromocriptine therapy and without lamotrigine , she had frequent sunct - like attacks of high intensity especially from the 6th to the 13th day of menstrual cycle . trials of drug reduction , performed every second month succeed after 6  months with complete headache resolution.fig . 1magnetic resonance imaging ( mri ) scan of the brain revealed a pituitary adenoma on the right side of the gland without extending towards the cavernous sinus magnetic resonance imaging ( mri ) scan of the brain revealed a pituitary adenoma on the right side of the gland without extending towards the cavernous sinus the presented patient with frequent short - lasting attacks of pain associated with conjunctival injection , lacrimation and facial flushing fulfills the criteria for sunct syndrome . as for other tacs , strictly unilateral pain localization in sunct syndrome is an obligatory diagnostic criterion . the exceptions from this rule with bilateral pain presentation were described for primary sunct [ 9 , 10 ] . however , bilateral presentation of pain was more frequently observed in symptomatic cases . in large group of patients with pituitary tumors - associated headache , moreover , diagnostic criteria for headaches attributed to hypothalamic or pituitary hyper- or hypo - secretion , coded 7.4.4 by the current classification , included bilateral pain presentation . incomplete response to carbamazepine , observed in our patient , has been described by other authors , as well [ 11 , 12 ] . the existing evidence favors lamotrigine and , according to a recent drug trial , topiramate   as the most effective therapies for sunct syndrome [ 3 , 11 ] . the effectiveness of lamotrigine in our patient with symptomatic headache underlines that good response to therapy does not exclude the need for extensive diagnostic work - up in order to exclude the underlying pathology . in other words , good response to lamotrigine could not be considered as diagnostic criteria for sunct , like indomethacin for paroxysmal hemicrania and hemicrania continua . there was no evidence of tumor extension to the cavernous sinus or surrounding brain structures in the presented patient . the pain had equal intensity , duration , frequency and quality on both sides as reported by the patient . these features support the current opinion that the pituitary - associated headache is predominantly neurohumorally mediated by disruption of the dopamine after 2  months of bromocriptine therapy , when the prolactin serum levels were within physiological range and cycle became ovulatory , our patient experienced partial improvement . in that time , sunct - like headaches were occurring only between 6th and 13th day of menstrual cycle , in follicular phase when the estrogen levels were increased . it is demonstrated , on animal model , that high levels of estrogen influence gene expression and intracellular signaling regulated by kinase , following the up - regulation of cell receptors on pathways for inflammatory and neuropathic pain . recent neuropharmacological evidence from a primate model of surgical menopause examining effects in the dorsal raphe of macaques suggests that serotonin synthesis and degradation , as well as the neuronal firing are influenced by estrogen receptor - mediated mechanisms . however , it is worth noting that the autonomic features were more prominent ipsilateral to the side of the tumor . the obvious tumor compression of surrounding tissue was not detected , but the possible local impact on autonomic pathways could not be excluded . bromocriptine therapy decreased serum prolactin levels to normal values only after 2  months , while the headaches resolved after 6  months of therapy , requiring simultaneous treatment with lamotrigine . the plausible explanation for the observed time lag and partial efficacy of bromocriptine therapy could be different mechanisms of drug action on dopamine  prolactin axis and trigeminovascular system .
short - lasting unilateral neuralgiform headache with conjunctival injection and tearing ( sunct ) syndrome is a rare trigeminal autonomic cephalalgia . 
 the cases of sunct with attacks that affected both sides simultaneously have only rarely been reported and some of them had underlying pathology . 
 we have reported a case of bilateral sunct - like headache secondary to a prolactinoma and responsive to lamotrigine treatment .