- Trigeminal Autonomic Cephalalgias Following Unilateral Dorsolateral Medullary Infarction: A Case Series and Literature Review
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Jae-Myung Kim, Hak-Loh Lee, You-Ri Kang, Joon-Tae Kim, Seung-Han Lee
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Received August 10, 2025 Accepted September 17, 2025 Published online October 2, 2025
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DOI: https://doi.org/10.62087/hpr.2025.0013
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 Abstract
- Purpose: Secondary trigeminal autonomic cephalalgias (TACs) are typically associated with posterior fossa abnormalities, such as tumors and vascular malformations. However, TACs following brainstem ischemic lesions have rarely been reported. This study aimed to determine the clinical characteristics and anatomical substrates of TACs after unilateral dorsolateral medullary infarction.
Methods
Four patients (three males; mean age, 58.2 years) with secondary TACs resulting from dorsolateral medullary infarction, diagnosed according to the International Classification of Headache Disorders, third edition criteria, were analyzed. All patients underwent detailed neurological examinations and neuroimaging, including diffusion-weighted magnetic resonance imaging and magnetic resonance angiography. Additionally, five published cases were identified through a literature review and analyzed in conjunction with our cohort.
Results
All patients exhibited stabbing or electric shock-like pain in the ipsilateral periorbital, hemifacial, and temporal regions. Headaches developed weeks to months after stroke onset with brief attacks (1–2 minutes) occurring 1–5 times daily. Lacrimation (100%) and conjunctival injection (75%) were common autonomic features. Three patients were diagnosed with short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), while a fourth had short-lasting unilateral neuralgiform with cranial autonomic symptoms (SUNA). Each patient, as well as four of the five from the literature, exhibited ipsilateral facial sensory loss, suggesting involvement of the trigeminal spinal tract and nucleus. Later headache onset appeared to be associated with persistent symptoms.
Conclusion
Headache characteristics in these cases were more consistent with SUNCT or SUNA than with typical cluster headaches. The presence of focal neurological signs highlights the importance of careful neurological examinations and neuroimaging for identifying secondary causes. Clinicians should consider secondary TACs in patients with new-onset SUNCT/SUNA and focal brainstem signs.
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