3.3.2.1 Episodic SUNA

Patient Identification

Name: M.S.R.
Age: 42 years
Gender: Female
Occupation: Teacher
Marital Status: Married
Origin: São Paulo, SP

Chief Complaint
"Very severe headaches on the right side that last a few minutes but are terrible."

History of Present Illness
The patient reports a headache condition that began approximately 8 months ago, characterized by episodes of unilateral right-sided pain, with severe intensity (9/10 on the visual analog scale), lasting between 30 seconds to 3 minutes. The attacks occur in periods of 4-6 weeks, with a frequency of 15-20 episodes per day during active periods, followed by complete remissions of 2-4 months. During active episodes, the attacks predominantly occur in the afternoon and evening, with some nocturnal awakenings. The pain is described as "intense burning" or "electric shock" in the right temporal region, occasionally radiating to the orbital and upper maxillary region on the same side. No consistent mechanical triggers have been identified by the patient. During the attacks, she presents with:

Intense ipsilateral tearing
Right nasal congestion
Unilateral clear rhinorrhea
Mild right eyelid ptosis
Sensation of "blocked ear" on the right
Mild motor restlessness

Denies photophobia, phonophobia, nausea, or vomiting during the episodes. There is no aura preceding the attacks.

Past Medical History

Episodic migraine since age 20 (last attack 6 months ago)
Hypothyroidism on levothyroxine 75mcg/day
Denies head trauma, previous surgeries, or other neurological comorbidities

Family History

Mother with migraine
Father hypertensive
Denies family history of cluster headaches or other trigeminal autonomic cephalalgias

Lifestyle Habits

Non-smoker, non-drinker
Regular physical activity (walking 3x/week)
Regular sleep, 7-8 hours/night
Denies frequent use of abortive medications

Physical Examination
General Examination

Good general condition, well-colored, hydrated, non-icteric
BP: 120/80 mmHg, HR: 72 bpm, Temp: 36.2°C
Weight: 65kg, Height: 1.65m, BMI: 23.9 kg/m²

Neurological Examination

Patient conscious, oriented, cooperative
Higher cortical functions preserved
Cranial nerves: no abnormalities
Muscle strength: grade V in all segments
Tendon reflexes symmetrical and present
Coordination and balance normal
Normal gait
No meningeal signs
Fundoscopy: no papilledema or other abnormalities

Headache Examination

During interictal period at the time of consultation
Palpation of the right temporal region without tender points
Absence of signs of permanent Horner's syndrome
Cervical movement without limitations

Complementary Exams
Cranial Magnetic Resonance Imaging

Brain structures with normal signal, morphology, and dimensions
Absence of expansive, ischemic, or hemorrhagic lesions
Ventricular system of normal dimensions
Absence of alterations in the posterior fossa or sellar region

Laboratory

Complete blood count: normal
Fasting glucose: 85 mg/dL
TSH: 2.1 mIU/L (normal on levothyroxine)
Free T4: 1.2 ng/dL