Primary headache associated with sexual activity …

Yen-Chi Yeh MD

Headache & Pain

Updated 03.02.2026
Released 08.14.1996
Expires For CME 03.02.2029

Primary headache associated with sexual activity

Author: Yen-Chi Yeh MD

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Editor: Shuu-Jiun Wang MD

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Primary headache associated with sexual activity

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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 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."

Wolff was the first to recognize that a benign headache syndrome could arise in association with sexual activity (46). The condition has been given a number of names, including "orgasmic cephalgia," "benign coital cephalgia," "coital headache," or "benign sexual headache" (38; 10; 23).

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 (22).

Clinical manifestations

Presentation and course

Sexual intercourse and climax may be associated with a marked increase in heart rate and blood pressure, which may cause headache directly or indirectly. In addition, headaches may occur during sexual activities associated with or independent of intercourse (eg, masturbation and watching pornography) (09) or orgasm. Men are affected much more often than women, which may, in some circumstances, relate to the degree of physical exertion in the sexual act. The age at onset ranges from the second through the sixth decades of life, with a mean age of 40 years (06). Rare cases of sexual headaches in adolescents as young as 12 years have been reported (19).

Forty percent of patients with sexual headaches also experience benign exertional headache (44; 13). A personal or family history of migraine is common but not absolute (25; 44; 36; 13). Headaches are more frequent during attempts to have several orgasms during one sexual encounter.

Primary headache associated with sexual activities is now regarded as a single entity with variable presentation (Table 1) (22).

Table 1. Diagnostic Criteria for Primary Headache Associated with Sexual Activity (ICHD-3)

Description: Headache precipitated by sexual activity, usually starting as a dull bilateral ache as sexual excitement increases and suddenly becomes intense at orgasm, in the absence of any intracranial disorder.
	A. At least two episodes of pain in the head and/or neck fulfilling criteria B-D B. Brought on by and occurring only during sexual activity C. Either or both of the following:
		1. increasing in intensity with increasing sexual excitement 2. abrupt explosive intensity just before or with orgasm
	D. Lasting from one minute to 24 hours with severe intensity and/or up to 72 hours with mild intensity E. Not better accounted for by another ICHD-3 diagnosis.

Of note, the ICHD-3 diagnostic criteria of primary headache associated with sexual activities introduce the term “only.” Therefore, patients with other forms of primary headache that can be precipitated by sexual activity, such as migraine or primary exertional headache, should be excluded from this diagnosis (34).

Headaches associated with sexual activity appear to have an unpredictable clinical pattern. They may appear suddenly, continue to occur for months to years, and stop abruptly, or they may occur regularly for many years (23; 36). Approximately one-quarter of patients run a chronic disease course (greater than or equal to 1 year) (18). The headache may not occur with every attempt at sexual activity or may occur to an extent that proscribes any sexual intercourse.

Prognosis and complications

The prognosis for recovery is excellent. Frese and colleagues followed 60 patients with benign headache associated with sexual activity and over a 3-year period found a remission rate of 69% (18).

An association between primary headache associated with sexual activity and migraine is reported in approximately 50% of cases (21).

Fifty-one patients with the diagnosis of headache associated with sexual activity had a high comorbidity with migraine (25%), benign exertional headache (29%), and tension-type headache (45%) (16).

Clinical vignette

Case 1. A 46-year-old man noted the onset of headache with sexual activity for the first time one week earlier. During intercourse, he noted a painful, tight sensation in the suboccipital and occipital regions. This pain increased as he neared climax. At orgasm, he experienced an explosive, severe, holocranial headache that was sharp and aching in character. The pain was so severe that he immediately ceased any activity and collapsed into the fetal position. This severe pain lasted for five to 10 minutes and began to remit slowly. The patient was taken to a local emergency room, where there was no meningismus, and neurologic examination and head CT were normal. Several days later, the patient again attempted sexual intercourse and noted the same premonitory pain. He stopped the intercourse, and the pain did not worsen and then remitted.

Case 2. A 43-year-old woman noted the onset of severe bilateral headache during sexual intercourse. It built to a peak of severe headache at orgasm. The headache was not associated with nausea, photophobia, or phonophobia, and would remit within 30 to 60 minutes. She could prevent the severe, explosive headache from occurring by preventing orgasm when she experienced the premonitory headache. She was treated with indomethacin before intercourse and had partial improvement. She was followed for two years, and the intercourse-related headache remitted after the first year.

Case 3. A 41-year-old woman had a 20-year history of headaches. The headaches were associated with nausea and light and noise sensitivity. For about five years, 90% of her orgasms were accompanied by the immediate development of a typical headache. She had no aura, and the headache could last as long as three days. Neurologic examination was normal, as was MRI of the head. A diagnosis of migraine with benign coital cephalgia was made.

Most patients who reported headache with orgasm or with proximity to orgasm often find that they get no headache or only a mild headache if sexual activity is not allowed to proceed to orgasm.

Biological basis

Etiology and pathogenesis

The pathophysiology of primary headaches associated with sexual activities remains unclear. A study of cerebral hemodynamics showed that patients with an explosive type of sexual headache had both a higher increase of cerebral blood flow velocity and a lower decrease of the pulsatility index of the middle cerebral artery after the acetazolamide test in comparison with healthy subjects (14). The data suggested an impairment of the metabolic rather than the myogenic component of the cerebral vaso-neuronal coupling.

Sharing similar clinical profiles, the cohort study suggested that primary headache associated with sexual activity and reversible cerebral vasoconstriction syndrome presented with sexual headache may be of the same disease spectrum (28). Therefore, the pathogenesis of reversible cerebral vasoconstriction syndrome, such as dysfunction of cerebral vascular tone and impairment of the blood-brain barrier, may also play key roles in primary headache associated with sexual activities (08).

One study hypothesized that benign headaches related to sexual activity may have a venous origin (13). This group speculates that venous stenosis could cause asymptomatic raised intracranial pressure in patients that promotes short-lasting paroxysms of increased CSF pressure and venous pressure with Valsalva exercises, exertion, or sexual activity, leading to the abrupt onset of short-lasting headaches. However, the group failed to support this hypothesis with MR venography on their patient cohort.

Risk factors associated with sexual headaches include: hypertension, obesity, lack of exercise, psychosexual stress (including extramarital affairs), the degree of sexual excitement, kneeling position during sexual intercourse, history of migraine or exertional headache, and family history of headache and occlusive arterial disease (37; 24; 32; 03).

Two reports have described the familial occurrence of sexual headache (23; 45).

Coital headache may arise as a side effect of sexual stimulants such as amyl nitrite, marijuana, amphetamines, and some commonly used anxiolytics as well as Sildenafil (20). In a meta-analysis of sildenafil for male erectile dysfunction, headache was reported in 11% of patients (15).

Differential diagnosis

Confusing conditions

Table 2. Secondary sexual headache may be related to the following causes

	• Subarachnoid hemorrhage (gross hemorrhage or leak), related to aneurysm, arteriovenous malformation, or angioma rupturing during sexual activity
	• Headache due to distension of aneurysm
	• Headache with carotid or vertebral dissection
	• Headache associated with stroke during sex
	• Headache due to CNS vasculitis related to amine-related drugs (amphetamine, cocaine) taken as “recreational” drugs
	• Headache due to drugs taken specifically to enhance sexual pleasure
	• 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
	• Headache related to muscle tension, muscle rupture, or fascial tear in the neck related to sexual activity
	• Low CSF pressure headaches due to dural leak
	• Reversible cerebral constriction syndrome

Most coital headaches are benign, but some are malignant. Headache and subarachnoid hemorrhage may be the most frequent neurologic emergencies that lead to sexual activity-related emergency department admissions (39).

Associated or underlying disorders

The radiological study reported that the most common sexual intercourse-associated pathology of emergency department admissions was headache attributed to cerebrovascular insult (40.3%) (40). Of the patients with headache attributed to nontraumatic intracranial hemorrhage, subarachnoid hemorrhage (66.6%) was the most common, followed by intracerebral bleeding (19.0%) and one subdural hemorrhage.

It is estimated that sexual intercourse is the precipitating cause of subarachnoid bleeding in 3.8% to 12% of patients with saccular aneurysms and in 4.1% of patients with arteriovenous malformations (29; 30; 01). Vomiting, meningitis, disturbance of consciousness, and residual pain the day after the incident characterize the headache caused by subarachnoid hemorrhage and help to distinguish it from that of benign orgasmic cephalgia. The alert clinician must be aware that a severe and disabling headache at the time of intercourse may result from subarachnoid bleeding. Other considerations include carotid/vertebral dissection (11), and cerebral or brainstem infarction with headache has been reported (25; 33).

Reversible cerebral vasoconstriction syndrome is increasingly being recognized as a cause of sexual headache, with 18 of 30 cases of multiple headaches associated with sexual activity seen over a 5-year period showing evidence of reversible cerebral vasoconstriction syndrome on MRA (47). The cohort study reported that repeated sexual headaches were predominantly secondary (28). Of 245 patients, 38 (15.5%) had primary headache associated with sexual activity, 174 (71.0%) had reversible cerebral vasoconstriction syndrome, 26 (10.6%) had probable reversible cerebral vasoconstriction syndrome, and seven (2.9%) had other vascular disorders. Of note, 26% of the patients with primary headache associated with sexual activity had a three times greater chance of running a chronic course (greater than or equal to 1 year) than patients with reversible cerebral vasoconstriction syndrome. Furthermore, having sexual activities as a trigger has been reported as a potential predictor of recurrent reversible cerebral vasoconstriction syndrome (07).

References

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Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Author

Yen-Chi Yeh MD

Dr. Yeh of Kuo General Hospital in Taiwan has no relevant financial relationship to disclose.
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Editor

Shuu-Jiun Wang MD

Dr. Wang of National Yang-Ming University and Taipei Veterans General Hospital received research grants from AbbVie, Lundbeck, Pfizer, Novartis, and Orient Europharma as principal investigator. He received speaker honorariums from AbbVie, Biogen, Eli Lilly, Hava Biopharma, and Pfizer.
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Former Authors

Robert A Davidoff MD
Hamid R Sami MD MSc
James R Couch MD PhD
Paul A Shanahan MRCPI BAO
Sarah Miller MRCP
Manjit S Matharu PhD MRCP

Patient Profile

Age range of presentation: 13 to 64 years
Sex preponderance: male>female, >4:1
Heredity: none
Population groups selectively affected: none selectively affected
Occupation groups selectively affected: none selectively affected

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Primary headache associated with sexual activity

Differential Diagnosis

rupture of a saccular aneurysm
arteriovenous malformation
carotid/vertebral artery dissection
stroke
migraine
- reversible cerebral vasoconstriction syndrome
- headache associated with low cerebrospinal fluid pressure

Primary headache associated with sexual activity

Cite this article

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Table 1. Diagnostic Criteria for Primary Headache Associated with Sexual Activity (ICHD-3)

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Table 2. Secondary sexual headache may be related to the following causes

Associated or underlying disorders

Diagnostic workup

Management

Special considerations

Pregnancy

Anesthesia

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

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Questions or Comment?

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