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Dear Sir We read with interest the article ‘Hot Moreover, the type of headache that they describe bath-related headache controlled by topiramate’ by in their patient following a hot bath also seems to Lee et al. (1) and wish to comment on some omis- have some features of migraine in terms of sever- sions in their article and also seek their response to ity, throbbing nature, and the presence of nausea and vomiting; the hot bath and exposure to cold We wish to draw the attention of the authors to could well have been a trigger for these atypical our article on ‘Hair wash or head bath triggering migraine headaches. Response to an established migraine – observations in 94 Indian patients’ (2, 3) antimigraine prophylactic like topiramate is wherein we have highlighted the beneficial effect of therefore not an unexpected finding in a patient antimigraine prophylaxis on headache following a head bath. The headache in our patients was dif- Their case report therefore only highlights an ferent from the type 1 bath-related headache (BRH) uncommon clinical presentation of a migrainous as categorized by Mak et al. (4) and more closely headache. Response to topiramate in a similar situ- resembled the type 2 BRH described by Mungen ation has been reported earlier (2). Bath-related et al. (5). We have also stated that there was a headache (BRH) is a clearly different, easily distin- decrease in the attack frequency following prophy- guishable category of headache that still defies lactic treatment to the point of the patients being explanation and has no specific line of manage- able to resume their normal bathing habit once ment. It would be premature to consider topiramate under treatment. As specified in the article topira- for the treatment of these headaches unless the mate was one of the prophylactics that was found to be entity is more clearly defined. If these headaches are indeed atypical presentations of migraine, then On reading through the details of the types of it is no surprise that topiramate is effective in headache in their case report, the following issues controlling the frequency and severity. We look forward to hearing from the authors.
1 It is well established that breeze and wind can be
a trigger for migraine headaches, e.g. Chinookwinds in Canada and the Sharev winds of Israel References
(6). Why then can the second type of headache, 1 Lee J., Yun C-H., Chu M-K., Ha C-K. Hot bath-related which they refer to as cold stimulus headache headache controlled by topiramate. Cephalalgia 2007; (CSH), not be an atypical migraine headache triggered by cold breeze and wind hitting the 2 Ravishankar K. ‘Hair wash’ or ‘head bath’ triggering migraine – observations in 94 Indian patients. Cephalalgia 2 Attempting to group a headache induced by
environmental cold temperature and cold breeze 3 Ravishankar K. ‘Hair-wash headache’ – an unusual trigger for migraine in Indian patients. Cephalalgia 2005; hitting the head and face in the same category as headache induced by head and body contact 4 Mak W, Tsang KL, Tsoi TH, Au Yeung KM, Chan KH et al.
with hot or cold water, I feel may lead to mis- Bath-related headache. Cephalalgia 2005; 25:191–8.
5 Müngen B, Bulut S. Hot bath-related headache: four cases migraine as a new type of temperature-related with headaches occurring after taking a hot bath. Ceph- 3 The patient in their case report did not have
6 Cooke LJ, Rose MS, Becker WJ. Chinook winds and migraine headache. Neurology 2000; 54:302–7.
thunderclap headaches, the headaches were longlasting with no need for acute management and K. Ravishankar, MD, The Headache and Migraine Clinics, Jaslok there was no spontaneous remission. So these and Lilavati Hospitals, Mumbai, India headaches cannot also be labelled as type 1 BRH.
Blackwell Publishing Ltd Cephalalgia, 2008, 28, 97–98
migraine, led to a diagnosis of HBRH for our patient. However, the responsiveness to topiramate Dear Sir We appreciate Dr Ravishankar’s interest and characteristics of HBRH suggest that HBRH in and valuable comment on our paper (1). We might share some pathophysiological mechanism agree that our patient shares some clinical features with ‘hair wash’ or ‘head bath’ triggering migraine Dr Ravishankar also raised the question about (HWB) (2). As Dr Ravishankar mentioned, the the diagnosis of cold-stimulus headache (CSH).
headache is stereotyped, closely related to hot- CSH is a type of primary thunderclap headache bathing, throbbing in nature, intermittently (not featuring a severe intensity, sudden onset evolving always) associated with nausea and vomiting, and in less than 1 min, and transient nature (3). As we responsive to a kind of antimigraine prophylaxis, described in the report, severe headache is more i.e. topiramate. However, the headache in our abruptly developed than HBRH, which usually patient developed just after pouring hot water and evolved over 2 to 3 min, and more severe in inten- reached maximum intensity within 2 to 3 min sity, but lasted for an unusually long period (1). The during the bath, which is different from HWB.
longer duration is somewhat confusing, but confers HWB usually developed during drying the hair or the uniqueness of both hot bath- and cold-induced the body after leaving the bathroom and could be prevented by using a hair dryer (2). Also, the head-ache was triggered exclusively by hot bath,although a certain group of HWB (11 of 1500 References
migraineurs and of 94 HWB) has hair wash or bathas the only trigger (1, 2).
1 Lee J, Yun CH, Chu MK, Ha CK. Hot bath-related head- As for now, the underlying pathological mecha- ache controlled by topiramate. Cephalalgia 2007; 27:465–7.
nism of the hot bath-related headache (HBRH) has 2 Ravishankar K. ‘Hair wash’ or ‘head bath’ triggering not been established and HBRH is not included in migraine – observations in 94 Indian patients. Cephalalgia2006; 26:1330–4.
the International Classification of Headache Disor- 3 Headache Classification Subcommittee of the International ders (ICHD-II) (3). Previous reports defined HBRH Headache Society. The international classification of head- on the basis of a characteristic triggering factor, i.e.
ache disorders: 2nd edn. Cephalalgia 2004; 24:9–160.
hot bath, and the specific temporal relationship 4 Negoro K, Morimatsu M, Ikuta N, Nogaki H. Benign hot between the trigger and headache (4–7). Therefore bath-related headache. Headache 2000; 40:173–5.
the stereotyped headache in our patient can be 5 Liao YC, Fuh JL, Lirng JF, Lu SR, Wu ZA, Wang SJ.
diagnosed as HBRH, although it does not perfectly Bathing headache: a variant of idiopathic thunderclapheadache. Cephalalgia 2003; 23:854–9.
match with type 1 or 2 of HBRH (1, 6). However, 6 Mak W, Tsang KL, Tsoi TH, Au Yeung KM, Chan KH et al.
considering the throbbing nature of the headache Bath-related headache. Cephalalgia 2005; 25:191–8.
and previous reports of the association between 7 Müngen B, Bulut S. Hot bath-related headache: four cases temperature stimuli and migraine, our patient with headaches occurring after taking a hot bath. Ceph- might be classified as having migraine or probable migraine (3). Taking this point of view, some pre-viously reported HBRH patients could also be diag- Jeong Lee1, Chang-Ho Yu1, Min-Kyung Chu2 and Choong-Kun nosed as having migraine (4–7). The presence of Ha1, 1Department of Neurology, Inha University Hospital, InhaUniversity College of Medicine, Incheon, and 2Department of uncommon features of migraine, i.e. hot-bath as an Neurology, Hallym University College of Medicine, Anyang, exclusive trigger, association with cold-induced headache, and no personal and family history of Blackwell Publishing Ltd Cephalalgia, 2008, 28, 97–98


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Mina Amezcua 3726 Las Vegas Blvd, Suite 309w, Las Vegas, NV, 89158562-842-5024 EDUCATION 2009-Current University of Nevada School of Medicine, Las Vegas, NV OB/GYN Residency Albany Medical College, Albany, NY , M.D. University of California – Los Angeles , C.A. B.S., Psychology-Biology CERTIFICATE/LICENSURE 2011 RESEARCH EXPERIENCE 2011-

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