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  • Updated 08.01.2020
  • Released 08.14.1996
  • Expires For CME 08.01.2023

Primary headache associated with sexual activity

Introduction

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 three 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 (52). The condition has been given a number of names including "orgasmic cephalgia," "benign coital cephalgia," "coital headache," or "benign sexual headache" (34; 42; 09; 20).

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; 22; 23). 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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