Abstract
To the Editor,
The recent update on primary cough, exertional and sex headache (1) contained many useful clinical nuggets from authors who have written considerably and well on this topic over years. I would like to point out one treatment matter and a more conceptual issue.
The authors omit lumbar puncture (LP) as a treatment option in primary cough headache. This was described by Symonds (2) and again by Raskin (3). This correspondent has found, just as has been reported, that LP can be curative in about two in five patients. Since it is curative, it seems important to mention it as an option to patients. As Gonzalez-Quintanilla and colleagues (1) remark, the fact that indomethacin may act to reduce cerebrospinal fluid (CSF) pressure (4 –6) is all the more remarkable when one considers that some patients are cured by a transient reduction in CSF pressure through lumbar puncture and CSF removal. Indeed, we have offered a nitrergic mechanism as a possible contributor to the uniqueness of indomethacin's effect amongst NSAIDs (7,8). This is an area ripe for investigation.
The authors consider primary sex headache a form of exertional headache; this is open to discussion. This correspondent has seen patients with primary sex headache without physical exertion. Good taste limits a detailed description of the particular activities described, suffice to say one has seen patients who have experimented with methods of stimulation sufficient for orgasm without physical exertion and still had headache. Moreover, it has been this correspondent’s strong clinical impression that primary sex headache, when headache is not also triggered in the same patient by exertion or cough, is, almost always, benign. A confounding factor is migraine triggered by exertion, which is separate from primary exertional headache, and may have complicated the interpretation of Silbert and colleagues (see Table 2 in their article) (9). In summary, a reasonable clinical case can be made for the current ICHD-3 (10) division of these headache types, after careful consideration of intercurrent migraine, while further data are acquired.
