Abstract
Dear Sir We read with interest the article ‘Hot bath-related headache controlled by topiramate’ by Lee et al. (1) and wish to comment on some omissions in their article and also seek their response to certain queries.
We wish to draw the attention of the authors to our article on ‘Hair wash or head bath triggering migraine – observations in 94 Indian patients’ (2, 3) wherein we have highlighted the beneficial effect of antimigraine prophylaxis on headache following a head bath. The headache in our patients was different from the type 1 bath-related headache (BRH) as categorized by Mak et al. (4) and more closely resembled the type 2 BRH described by Mungen et al. (5). We have also stated that there was a decrease in the attack frequency following prophylactic treatment to the point of the patients being able to resume their normal bathing habit once under treatment. As specified in the article topiramate was one of the prophylactics that was found to be effective.
On reading through the details of the types of headache in their case report, the following issues need further clarification.
It is well established that breeze and wind can be a trigger for migraine headaches, e.g. Chinook winds in Canada and the Sharev winds of Israel (6). Why then can the second type of headache, which they refer to as cold stimulus headache (CSH), not be an atypical migraine headache triggered by cold breeze and wind hitting the head and face?
Attempting to group a headache induced by environmental cold temperature and cold breeze hitting the head and face in the same category as headache induced by head and body contact with hot or cold water, I feel may lead to misinterpretation of an atypically triggered migraine as a new type of temperature-related CSH
The patient in their case report did not have thunderclap headaches, the headaches were long lasting with no need for acute management and there was no spontaneous remission. So these headaches cannot also be labelled as type 1 BRH. Moreover, the type of headache that they describe in their patient following a hot bath also seems to have some features of migraine in terms of severity, throbbing nature, and the presence of nausea and vomiting; the hot bath and exposure to cold could well have been a trigger for these atypical migraine headaches. Response to an established antimigraine prophylactic like topiramate is therefore not an unexpected finding in a patient with these clinical features.
Their case report therefore only highlights an uncommon clinical presentation of a migrainous headache. Response to topiramate in a similar situation has been reported earlier (2). Bath-related headache (BRH) is a clearly different, easily distinguishable category of headache that still defies explanation and has no specific line of management. It would be premature to consider topiramate for the treatment of these headaches unless the entity is more clearly defined. If these headaches are indeed atypical presentations of migraine, then it is no surprise that topiramate is effective in controlling the frequency and severity. We look forward to hearing from the authors.