Primary headache associated with sexual activity

Yen-Chi Yeh MD (Dr. Yeh of Kuo General Hospital in Taiwan has no relevant financial relationship to disclose.)
Shuu-Jiun Wang MD, editor. (Dr. Wang of the National Yang-Ming University School of Medicine and the Neurological Institute, Taipei Veterans General Hospital received consulting fees from Eli Lilly.)
Originally released August 14, 1996; last updated April 10, 2016; expires April 10, 2019

This article includes discussion of primary headache associated with sexual activity, benign coital cephalgia, benign sexual headache, coital headache, and orgasmic cephalgia. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Sexually related headache may be primary or secondary. In this article, the author updates the discussion of primary headache associated with sexual activity. This headache can start as a dull bilateral ache with increasing sexual excitement or suddenly become intense with orgasm. Neuroimaging studies of both brain parenchyma and cerebral vasculature are recommended for all patients to exclude secondary causes. On the first onset, subarachnoid hemorrhage and arterial dissection must be ruled out. Reversible cerebral vasoconstriction syndrome should be considered until proven otherwise in those with multiple attacks of sexual headache.

Key points

 

• Evaluation of new-onset headache associated with sexual activity should exclude secondary causes.

 

• Secondary causes of headache associated with sexual activity include subarachnoid hemorrhage, arterial dissection, stroke, and reversible cerebral vasoconstriction syndrome.

 

• Prognosis of primary headache associated with sexual activity is good, with 69% of cases remitting at 3 years.

 

• Non-drug treatments include weight loss, an exercise program, a more passive role during intercourse, variation in positions, or limitation of sexual activity during a given day.

 

• Drug treatments include propranolol, indomethacin, and triptans.

Historical note and terminology

Headache related to sexual activity has been recognized since the time of Hippocrates, who first suggested that headache might be brought on by "immoderate venery." In modern times, headache has provided subject matter for comedians and is usually relegated to a stereotype of avoidance of sexual activity on the part of the female (“Not tonight dear, I have a headache”).

Wolff was the first to recognize that a benign headache syndrome could arise in association with sexual activity (Wolff 1963). The condition has been given a number of names including "orgasmic cephalgia," "benign coital cephalgia," "coital headache," or "benign sexual headache" (Martin 1973; Paulson and Klawans 1974; Couch 1993; Johns 1986).

The International Headache Society used the term "primary headache associated with sexual activity" because sexual headache may also be precipitated by masturbation and during nocturnal emissions; furthermore, it may occur without orgasm. Of note, this headache should be defined as primary headache after excluding various neurologic conditions brought out by sexual activity (Headache Classification Committee of the International Headache Society 2004; Headache Classification Committee of the International Headache Society 2013). Secondary sexual headache may be related to the following causes:

 

1. Subarachnoid hemorrhage (gross hemorrhage or leak), related to aneurysm, arteriovenous malformation, or angioma rupturing during sexual activity

 

2. Headache due to distension of aneurysm

 

3. Headache with carotid or vertebral dissection

 

4. Headache associated with stroke during sex

 

5. Headache due to CNS vasculitis related to amine-related drugs (amphetamine, cocaine) taken as “recreational” drugs

 

6. Headache due to drugs taken specifically to enhance sexual pleasure

 

7. Headache due to increased intracranial pressure related to physical activity due to sex. This is most important in subjects with a pre-existing condition such as Arnold-Chiari malformation or space-occupying lesion

 

8. Headache related to muscle tension, muscle rupture, or fascial tear in neck related to sexual activity

 

9. Low CSF pressure headaches due to dural leak

 

10. Reversible cerebral constriction syndrome

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