Abstract
Dear Sir We are pleased to have the opportunity to answer Dr Rapoport's letter on our publication ‘Treatment of cluster headache with topiramate: effects and side effects in five patients’.
We thank Dr Rapoport and his colleagues for their comments. We agree with their opinion that topiramate offers an interesting alternative for the prophylactic treatment of even drug-resistant patients with cluster headache. This was one intention of our publication.
However, the side effects of topiramate, which are well known from treating epilepsy (1–3), might be a limiting factor that should not be underestimated. Of course, our patients might have suffered from fewer or more minor side effects, if we had prescribed topiramate in increments of only 12.5 mg. But this means to increase the dose of topiramate even more slowly than generally recommended. The five patients on whom we reported were all treated according to the guidelines of the drug manufacturer. To indicate that we slowly increased the doses in the patients with side-effects, we gave the exact dosage of topiramate in only those patients.
In summary, to utilize the prophylactic properties of topiramate in cluster headache, it may prove necessary to treat patients with lower increments than generally recommended for the treatment of epilepsy. Therefore, treatment of cluster headache with topiramate should be restricted to neurologists who are familiar with the side-effects of this drug that are obviously dependent on the titration rate (4).