A review of 50 cases of bath-related headache: clinical features and possible diagnostic criteria

Silva-Néto, Raimundo Pereira

doi:10.1590/0004-282X20180039

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Arquivos de Neuro-Psiquiatria

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View and Review • Arq. Neuro-Psiquiatr. 76 (5) • May 2018 • https://doi.org/10.1590/0004-282X20180039 copy

A review of 50 cases of bath-related headache: clinical features and possible diagnostic criteria

Uma revisão de 50 casos de cefaleia relacionada ao banho: características clínicas e possíveis critérios diagnósticos

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To describe clinical features and possible diagnostic criteria of the 50 bath-related headache (BRH) cases that have been published in the literature to date.

Methods:

Based on a literature search in the major medical databases, we analyzed all case reports or case series on BRH that were published between 2000 and 2017.

Results:

We describe 48 women and two men diagnosed with BRH. Of these 50 patients, 90% were from Asian countries. The average age was 49.3 years. There was an association of BRH with migraine (28%), tension-type headache (12%) and cold stimulus headache (4%). Headache was bilaterally localized, had an explosive or pulsating quality and a severe intensity. The pain lasted from five minutes to four days. Associated manifestations were nausea, vomiting, photophobia or phonophobia. There was a good therapeutic response with nimodipine and when avoiding a hot bath.

Conclusions:

Bath-related headache is a benign headache that is not associated with a structural lesion.

Keywords:
headache disorders; diagnosis; drug therapy

Published studies	Sex	Age (years)	Other headaches	In relation to the bath	Location of pain	Quality of pain	Duration of pain	Associated symptoms	Imaging studies	Prophylactic treatment
Negoro et al.,¹1. Negoro K, Morimatsu M, Ikuta N, Nogaki H. Benign hot bath-related headache. Headache. 2000 Feb;40(2):173-5. https://doi.org/10.1046/j.1526-4610.2000.00026.x https://doi.org/10.1046/j.1526-4610.2000... 2000 [3 patients in Japan]	F	54	TTH	pouring hot water over herself	ND	not throbbing	5–10 min	floating sensation	CT/MRI/MRA were normal	by avoiding taking a hot bath
	F	49	ND	pouring hot water over herself	frontal and right occipital	explosive	1–4 h	No	CT/MRI/MRA were normal	by avoiding taking a hot bath
	F	47	ND	soaking in a hot bath	bitemporal	throbbing	60 min	nausea	MRI/MRA were normal	by avoiding taking a hot bath
Liao et al.,²2. Liao YC, Fuh JL, Lirng JF, Lu SR, Wu ZA, Wang SJ. Bathing headache: a variant of idiopathic thunderclap headache. Cephalalgia. 2003 Nov;23(9):854-9. https://doi.org/10.1046/j.1468-2982.2003.00603.x https://doi.org/10.1046/j.1468-2982.2003... 2003 [4 patients in Taiwan]	F	51	No	pouring hot water over herself	vertex	pulsatile	6 h	nausea	MRI/MRA showed vasospasm	nimodipine
	F	53	No	pouring hot water over herself	frontal-vertex	explosive	7–8 h	blurred vision	MRI/MRA were normal	nimodipine
	F	32	ND	pouring hot water over herself	neck-to-vertex	pulsatile	2 h	No	MRI/MRA were normal	nimodipine
	F	53	ND	pouring hot water over herself	left-sided	explosive	5–30 min	ND	MRI/MRA were normal	by avoiding taking a hot bath
Müngen and Bulut,⁴4. Müngen B, Bulut S. Hot bath-related headache: four cases with headaches occurring after taking a hot bath. Cephalalgia. 2003 Oct;23(8):846-9. https://doi.org/10.1046/j.1468-2982.2003.00562.x https://doi.org/10.1046/j.1468-2982.2003... 2003 [4 patients in Turkey]	F	29	Migraine	getting out of a hot bath	bifrontal	not throbbing	60–90 min	ND	CT/MRI were normal	ND
	F	18	Migraine	getting out of a hot bath	occipital	not throbbing	60–90 min	No	CT/MRI were normal	ND
	M	34	TTH, CSH	getting out of a hot bath	generalized	not throbbing	30–60 min	No	CT/MRI were normal	ND
	F	38	Migraine	getting out of a hot bath	bifrontotemporal	not throbbing	3–6 h	No	CT/MRI were normal	ND
Mak et al.,⁵5. Mak W, Tsang KL, Tsoi TH, Au Yeung KM, Chan KH, Cheng TS et al. Bath-related headache. Cephalalgia. 2005 Mar;25(3):191-8. https://doi.org/10.1111/j.1468-2982.2004.00832.x https://doi.org/10.1111/j.1468-2982.2004... 2005 [6 patients in China]	F	67	ND	during a hot bath	bitemporal	throbbing	60–90 min	ND	CT was normal	sumatriptan
	F	50	ND	during a hot bath	generalized	throbbing	60 min	ND	CT was normal	amitriptyline
	F	51	ND	during a hot bath	frontal	ND	30 min	ND	CT was normal and MRI showed nonspecific neuroradiological findings	sodium valproate
	F	47	ND	during a hot bath	right occipital	throbbing	1–4 h	nausea and vomiting	CT was normal	ND
	F	58	TTH	during a hot or cold bath	vertex	ND	2–9 h	vomiting, sweating, scalp tenderness, slurred speech and mild gait unsteadiness	CT was normal and MRI showed a small arachnoid cyst in the cerebellum	ND
	F	50	ND	during a hot bath	left-sided	ND	2–6 h	nausea and vomiting	TCD/MRI showed vasospasm	nimodipine
Ravishankar,⁶6. Ravishankar K. ‘Hair wash’ or ‘head bath’ triggering migraine - observations in 94 Indian patients. Cephalalgia. 2006 Nov;26(11):1330-4. https://doi.org/10.1111/j.1468-2982.2006.01223.x https://doi.org/10.1111/j.1468-2982.2006... 2006 [3 patients in India]	F	35	Migraine	hair wash or head bath	right hemicranium	throbbing	10–15 min	nausea, vomiting; photophobia and phonophobia	Examinations were normal	analgesic
	F	37	Migraine	head bath	left temporoparietal	throbbing	24–48 h	vomiting, phonophobia and shivering of the whole body	CT was normal	naproxen sodium or ergotamine
	F	19	Migraine	hair wash	occipital	ND	10–15 min	No	CT was normal	migraine prophylactic
Rossi and Nappi,⁷7. Rossi P, Nappi G. Bath-related headache: the first European case. Cephalalgia. 2006 Dec;26(12):1485-6. https://doi.org/10.1111/j.1468-2982.2006.01204.x https://doi.org/10.1111/j.1468-2982.2006... 2006 [1 patient in Spain]	F	57	Migraine	during a hot shower or wetting her skin with hot water	bitemporal	explosive	5 h	nausea, photophobia, phonophobia and dizziness	MRI/MRA were normal	propranolol
Lee et al.,⁸8. Lee J, Yun CH, Chu MK, Ha CK. Hot bath-related headache controlled by topiramate. Cephalalgia. 2007 May;27(5):465-7. https://doi.org/10.1111/j.1468-2982.2007.01308.x https://doi.org/10.1111/j.1468-2982.2007... 2007 [1 patient in South Korea]	F	34	CSH	during a hot bath	occipital	throbbing	3–4 days	facial flushing, nausea and vomiting	Not performed	topiramate
Tanaka and Okamoto,⁹9. Tanaka M, Okamoto K. Bath-related headache: a case report. Cephalalgia. 2007 Jun;27(6):563-5. https://doi.org/10.1111/j.1468-2982.2007.01322.x https://doi.org/10.1111/j.1468-2982.2007... 2007 [1 patient in Japan]	F	37	No	pouring hot water over her neck to wash her hair	ND	throbbing	4 h	nausea and vomiting	CT/MRI were normal	by avoiding taking a hot bath
Wang et al.,¹⁵15. Wang SJ, Fuh JL, Wu ZA, Chen SP, Lirng JF. Bath-related thunderclap headache: a study of 21 consecutive patients. Cephalalgia. 2008 May;28(5):524-30. https://doi.org/10.1111/j.1468-2982.2008.01541.x https://doi.org/10.1111/j.1468-2982.2008... 2008 [21 patients in Taiwan]	21F	32–76	Migraine (28.6%) and TTH (14.3%)	hot bath (76.2%), cold bath (9.5%), indifferent water temperature (14.3%)	bilateral (61.9%), vertex (33.3%) and ND (4.8%)	explosive (86%) and pulsatile (67%)	30–180 min	nausea, vomiting; photophobia or phonophobia	CT was normal (71.4%) and MRI showed vasospasm (61.9%)	by avoiding taking a hot bath (90%)
	21F	(54±8)	Migraine (28.6%) and TTH (14.3%)		bilateral (61.9%), vertex (33.3%) and ND (4.8%)	explosive (86%) and pulsatile (67%)	30–180 min	nausea, vomiting; photophobia or phonophobia	CT was normal (71.4%) and MRI showed vasospasm (61.9%)	nimodipine (90%)
Câmara Filho et al.,¹⁰10. Câmara Filho JW, Medeiros FL, Sougey EB. Bath-related headache: a Brazilian case report. Arq Neuropsiquiatr. 2012 May;70(5):383-4. https://doi.org/10.1590/S0004-282X2012000500015 https://doi.org/10.1590/S0004-282X201200... 2012 [1 patient in Brazil]	F	51	No	pouring hot water over herself	frontoparietal	ND	30 min	ND	MRI/MRA were normal	by avoiding taking a hot bath
Jhang et al.,¹¹11. Jhang KM, Lin CH, Lee KW, Chen YY. Bath-related thunderclap headache associated with subarachnoid and intracerebral hemorrhage. Acta Neurol Taiwan. 2013 Sep;22(3):127-32. 2013 [1 patient in Taiwan]	F	56	No	during a hot or cold bath	ND	explosive	ND	ND	CT/MRI/MRA showed acute SAH and CTA revealed vasoconstriction	nimodipine
Tanaka et al.,¹²12. Tanaka R, Ando M, Shimura H, Yamashiro K, Hattori N. Bath-related headache controlled by zolmitriptan. Neurol Clin Neurosci. 2015;3(5):200-2. https://doi.org/10.1111/ncn3.12008. https://doi.org/10.1111/ncn3.12008... 2015 [1 patient in Japan]	F	59	No	pouring hot water over herself	ND	explosive	ND	ND	MRA showed segmental vasoconstriction	zolmitriptan
Grangeon et al.,¹³13. Grangeon L, Ozel G, Guégan-Massardier E, Lefaucheur R. Bath-related thunderclap headache: case report of a male patient. Headache. 2016 Nov;56(10):1664-6. https://doi.org/10.1111/head.12900 https://doi.org/10.1111/head.12900... 2016 [1 patient in Africa]	M	36	No	during a hot bath	right-sided	explosive and pulsatile	< 24 hours	No	CT/MRI/MRA were normal	amitriptyline
Dantas et al.,¹⁴14. Dantas JH, Gomes JL, Pereira ML, Moreira FC, Coelho RF, Silva-Neto RP. Bath-related headache: two cases report in Brazil. Int J Case Rep Short Rev. 2017;3(3):57-9. 2017 [2 patients in Brazil]	F	63	Migraine	during a hot bath	frontoparietal bilaterally	throbbing	20 min	No	CT/MRI were normal	by avoiding taking a hot bath
	F	65	No	during a hot bath	right hemicranium	explosive	45–60 min	No	CT/MRI were normal	by avoiding taking a hot bath

Water temperature	Patients
Water temperature	N	%
Hot water	41	82
Cold water	2	4
Not indicated	7	14

Neuroradiological findings	Patients
Neuroradiological findings	n	%
No abnormalities	30	61.2
Vasospasm	17	34.7
Nonspecific changes	2	4.1

Suggested diagnostic criteria
A. At least two acute headache episodes fulfilling criteria B-D
B. The patient is taking a hot bath
C. Evidence of causation demonstrated by both of the following: headache developed during a hot bath, headache did not recur after avoiding hot baths
D. Headache has at least two of the following four characteristics: bilateral location, moderate or severe pain intensity, explosive or pulsating quality, lasting 60–180 minutes
E. Not better accounted for by another International Classification of Headache Disorders diagnosis

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[1] Correspondence: Raimundo Pereira Silva-Néto; UFPI; Avenida Frei Serafim, 2280; 64001-020 Teresina PI; Brasil; E-mail: neurocefaleia@terra.com.br