Clinical manifestations

Presentation and course

Sexual intercourse and climax may be associated with 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) (08), or orgasm. Men are affected much more often than women (4:1 ratio), 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 (17).

Forty percent of patients with sexual headaches also experience benign exertional headache (48; 12). A personal or family history of migraine is common but not absolute (24; 48; 38; 12). Headaches are more frequent during attempts to have several orgasms during one sexual encounter.

Traditionally, benign headaches or benign coital cephalgia associated with sexual activity were divided into three types:

(1) Preorgasmic tension-type headache. A dull, tight, cramping headache, usually bilateral and occipital/cervical in location, can occur during sexual activity. It usually intensifies as sexual excitement increases and is generally preorgasmic (23; 24).

(2) Orgasmic headache. Headaches with abrupt or explosive onset, in the occipital region, behind the eyes, or generalized, occur at orgasm (39). This type of headache builds as the subject approaches orgasm and then “explodes” to a severe, generalized headache with orgasm. The headache can be prevented by not allowing orgasm to occur. Such headaches are usually throbbing, of varying intensity, and rather short-lived with a duration of minutes to a few hours. They are the most common type associated with sexual activity (21; 38). Although the etiology is unknown, it has been postulated to be caused by the increased blood pressure that occurs during orgasm (23; 24). As the headache may outlast the elevation of blood pressure that occurs with sexual activity, this appears to be an incomplete or inadequate pathophysiologic mechanism. This type of headache appears to share clinical features with migraine, and some authors consider it to be a migraine variant (33; 24; 26; 44).

(3) Postorgasmic headache on standing. This headache, a result of low cerebrospinal fluid pressure, can result from a dural tear that occurred during the physiologic stress of coitus. The relationship of posture to pain in these patients is identical to that seen in patients with headache following lumbar puncture (41).

In 2004, The International Headache Society defined preorgasmic headache and orgasmic headache as two subtypes of primary headache associated with sexual activity; postorgasmic postural headache was classified as secondary headache (19). Because clinical studies have been unable to distinguish the two subforms of primary headache associated with sexual activity, this headache is now regarded as a single entity with variable presentation (20) (Table 1).

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 becoming 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 introduces 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 (36).

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 (21; 38). Approximately one-quarter of patients run a chronic disease course (greater than or equal to 1 year) (16). 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% (16).

An association between primary headache associated with sexual activity and migraine is reported in approximately 50% of cases (19).

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%) (14).

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 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 CT of head 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 headache. 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 mild headache if sexual activity is not allowed to proceed to orgasm.

Biological basis

Etiology and pathogenesis

Benign headaches related to sexual activity can be caused by excessive cervical and facial muscular contraction, a dural tear, or increased blood pressure. Lance has postulated a period of muscular contraction during the short period preceding climax and a vascular component related to hypertension at the time of climax (23; 24). Segmental vasospasm of cerebral arteries was documented by MRI or digital angiography before, during, and after resolution of the orgasmic headache (49). It has been hypothesized that benign headaches related to sexual activity may have a venous origin (12). 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 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 (40; 22; 32; 03).

Exertion and sexual activity can also produce headaches in patients who have mass lesions, structural malformations (eg, Chiari malformation), and vascular malformations. Bleeding from an aneurysm or arteriovenous malformation can cause headaches associated with sexual activity. The systemic physiological changes occurring during intercourse that may increase the risk of aneurysmal rupture are reviewed in a paper by Reynolds (46) and include hyperdynamic alterations in blood pressure, heart rate, respiratory rate, and muscle tone. Each of these factors increases the transmural pressure across the aneurysm wall by increasing the mean arterial blood pressure or decreasing the intracranial pressure, thus, increasing the risk of rupture.

Two reports have described the familial occurrence of sexual headache (21; 50).

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 (18). In meta-analysis of Sildenafil for male erectile dysfunction, headache was reported in 11% of patients (13).

According to Masters and Johnson, the basic physiologic response of both men and women to sexual stimulation is diffuse vasodilation followed by a secondary generalized increase in muscle tension (35). In particular, the neck and face muscles involuntarily contract. Elevations of blood pressure (as much as 50 mm Hg diastolic and 100 mm Hg systolic in men) are found at the time of orgasm (28; 37). The acute pressor response is comparable to the paroxysmal elevations in blood caused by pheochromocytomas. The headaches in both conditions resemble each other. It is unclear if the orgasmic headache is related to the increase in blood pressure, cerebral vasodilation, or other factors such as increase in neural activity, release of neurotransmitters, or both.

Epidemiology

Rasmussen and Olesen have assessed the lifetime prevalence of headache disorders in a cross-sectional epidemiologic survey of a representative 25- to 64-year-old general population (45). They found a lifetime prevalence of 1% for orgasmic headache. Others reported a prevalence of 0.21% to 1.3% (03).

Prevention

Headaches may be prevented in some patients by weight loss, an exercise program, a more passive role during intercourse, variation in positions, limitation of sexual activity during a given day, and drug therapy.

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 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 (42).

Associated or underlying disorders

Sharing similar clinical profiles, primary headache associated with sexual activity and reversible cerebral vasoconstriction syndrome presented with repeated attacks of sexual headache may be of the same disease spectrum (27). Furthermore, having sexual activities as a trigger has been reported a potential predictor of recurrent reversible cerebral vasoconstriction syndrome (07).

The radiological study reported that the most common sexual intercourse-associated pathology of emergency department admissions was headache attributed to cerebrovascular insult (40.3%) (43). 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 (10), also, cerebral or brainstem infarction with headache have been reported (24; 26; 34).

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 (52). The cohort study reported that repeated sexual headaches were predominantly secondary (27). Of 245 patients, 38 (15.5%) with primary headache associated with sexual activity, 174 (71.0%) with reversible cerebral vasoconstriction syndrome, 26 (10.6%) with probable reversible cerebral vasoconstriction syndrome, and 7 (2.9%) with other vascular disorders. Of note, 26% of the patients with primary headache associated with sexual activity had a 3 times greater chance of running a chronic course (greater than or equal to 1 year) than patients with reversible cerebral vasoconstriction syndrome.

Diagnostic workup

A careful history and physical examination are essential. All patients seen acutely and suspected of having a subarachnoid hemorrhage should have a CT scan and a lumbar puncture. Patients with chronic sexual headaches should have an MRI with MRA examination.

Management

The therapy of headaches associated with sexual activity is difficult to evaluate because of the capricious nature of the disorder. Treatment approaches are either nonpharmacological, such as abstinence, a passive role during intercourse, varying positions during sexual activities, weight reduction, increased exercise, biofeedback and relaxation therapy; or pharmacological, such as analgesics, antihistamines, antidepressants, as well as beta blockers and calcium channel blockers (03; 25). Greater occipital nerve blockade has been reported to be helpful in one case, with no recurrence of pain for 10 weeks of follow-up (47). For sex-induced vascular headaches that are severe and occur regularly, treatment with propranolol (40 to 240 mg a day) or other beta blockers has been successfully used in some patients (44). Indomethacin (25 to 75 mg/day on a regular or intermittent basis) has also been recommended (11), and triptans may be helpful in some cases if used preemptively for benign orgasmic headache (15). Response to topiramate has also been reported (04; 05). A patient comorbid with migraine has been successfully managed with erenumab (31).

Special considerations

Pregnancy

An unusual case of acute headache and hypertension occurring at the height of sexual excitement during the puerperium has been reported (02).

Anesthesia

This diagnosis does not preclude anesthesia as indicated or necessary.