Abstract
To the Editor,
We thank Professor Goadsby for his interest and comments on our recent review paper on exertional headaches (1). He is right that in our update we did not mention lumbar puncture as a treatment option in primary cough headache (2). We admit that we are skeptical about the real value of this invasive procedure in this, usually transient, primary headache due to several reasons. First, both Symonds’ (3) and Raskin’s (4) works appeared before the MRI era and therefore the certainty of a primary cough headache diagnosis was not possible. Second, we should be aware that lumbar puncture can be a reason for cough headache secondary to tonsillar descent due to low intracranial pressure. Finally, we are now in the era of evidence-based medicine and, besides Goadsby’s unpublished positive experience with two in five patients, we have only been able to find two further reports treating primary cough headache patients with lumbar puncture. Chen et al. treated 10 patients and eight of them had “much improvement or complete remission” (5), while Kesserwani reported just one patient who three times with low-volume drainage (3 cc) (6). With such evidence we do not routinely recommend lumbar puncture as a routine treatment of cough headache, though we agree it could be an option for patients with and in whom we need to examine the cerebrospinal pressure and/or composition, or in patients with no response, intolerance or contraindications to indomethacin.
We also concur with Goadsby’s comments on the relationship between primary sex headache and exertional headache. In general, the profiles of patients with both headaches are similar and many of them, in our experience, have headaches both with prolonged exertion and with sexual intercourse (2). However, some patients only have sex headache but do not practice other types of exercise and vice versa. Furthermore, due to the Valsalva maneuvers during sex, some patients with primary (and secondary) cough headache also have sex headache, which strongly complicates the relationship among these primary headaches. Therefore, we agree with Goadsby’s final comment that a reasonable clinical case should be made for the current ICHD-3 division of these exciting headache types, while further data are acquired.
