|Year : 2016 | Volume
| Issue : 1 | Page : 1-4
Headache associated with sexual activity: From the benign to the life threatening
Frank Aiwansoba Imarhiagbe
Department of Medicine, University of Benin Teaching Hospital, Benin City, Nigeria
|Date of Web Publication||6-May-2016|
Frank Aiwansoba Imarhiagbe
Department of Medicine, University of Benin Teaching Hospital, Benin City
Background: Neurologic syndromes like headache may on occasion complicate sexual activity. Though largely benign, the headache may seldom be a symptom of an underlying sinister and life threatening neurologic disorder such as aneurysmal subarachnoid heamorrhage. Method: Relevant published materials on the subject of headache associated with sexual intercourse and their cross references from Pubmed Medline, Cochrane Library, International Headache society, EMBASE and other relevant bibliographic repositories were ferreted since 1980 till date. Result: HAS is mainly a diagnosis of exclusion. The secondary or malignant form has a course that is dictated by its underlying cause. HAS in the primary or benign form is amenable to treatment with drugs including indomethacin, propranolol and calcium channel blockers (nimodipine, verapamil and diltiazem) with excellent prognosis. Conclusion: Early evaluation for underlying cause of HAS and institution of appropriate treatment is recommended.
Keywords: Headache, orgasm, subarachnoid haemorrhage
|How to cite this article:|
Imarhiagbe FA. Headache associated with sexual activity: From the benign to the life threatening. Sahel Med J 2016;19:1-4
| Introduction|| |
Headache associated with sexual activity (HAS) is an acute headache that is often related to sexual intercourse and it may be referred to as coital headache or orgasmic headache or orgasmic cephalagia because the headache may occur during orgasm, though it could also be preorgasmic (before orgasm). , HAS could be primary or secondary and in its primary or benign form, it is not associated with any underlying disease.  As per nosology, the primary form appears under "other primary headaches" with exertional and thunderclap headaches in the International Classification of Headache Disorders third edition (ICHD 3 beta) classification system of the International headache Society.  HAS is classified as secondary when it is associated with an underlying intracranial pathology, notable among which are cerebral artery aneurysms and other vascular disorders. 
It is known generally that headache and sex are not co-travelers on the same route and that the fear of HAS may become a potential reason for reduced frequency of sexual intercourse.  HAS dampens sexual drive and libido, as it is said to strip sex of pleasure and instead makes sex a "headache." 
In this article, potential sinister and life threatening causes of HAS are highlighted and the current approach to it is reviewed.
| History|| |
Headache associated with sexual activity has been described since the time of Hippocrates, but it first appeared in conventional literature in 1970 when the primary or benign form was described.  Historically HAS was for a long time thought to be a benign condition only with no treatment needed, but that view has since changed as literature has amassed considerably now on the subject. , Interest in HAS heightened when it became known that potentially sinister and life threatening disease conditions like aneurysmal subarachnoid haemorrhage could be underlying, meaning that HAS may not always be benign afterall.  It is pertinent to know that coitus has long been identified as the immediate preceding activity in some cases of ruptured aneurysmal subarachnoid haemorrhage and the whole essence of investigating HAS currently is to exclude such a life threatening condition. ,
| Epidemiology|| |
Headache associated with sexual activity is considered generally rare with a prevalence of about 0.3-0.9% and only very few present in the general Neurology clinic, though prevalence may be slightly more in a specialist headache and facial pain clinic. , It compares in frequency with exertional headaches with which it shares very many characteristics.  In a 10 years systematic review of activity related headaches like HAS, cough headaches and exertional headaches, HAS accounted for 18.6% of all the cases.  However, not a few believe that reported prevalence figures may be higher as most sufferers resort to self medication rather than seek help because of the perception of sex mainly as a very personal issue that should not be discussed openly.  Some others may dismiss it as entirely benign and inconsequential medically.  Reported prevalence figures are lower in other racial groups in comparison to the core western countries; this may derive from cultural reasons as regards discussions on sex and sexuality. , Males are more affected than females ,, and the mean age of onset from most series is between 34 and 40 years. , It is found to be commoner in those with a history of exertional headaches and migraine or a family history of migraine. ,,
| Classification|| |
Primary HAS appears nosologically in the ICHD 3 beta under "other primary headaches."  The secondary form is of varied aetiology and so appears under different sub-classifications depending on the identified underlying cause in the ICHD system. HAS could be preorgasmic or orgasmic.  It may also be classified as benign (innocuous) or malignant (when it is due to a sinister underlying cause like subarachnoid haemorrhage).  It is also classified distinctly as a form of activity related headache alongside cough and exertional headache.  Based on the time of onset of the headache in relation to sexual intercourse it has been differentiated into early HAS, which is usually of moderate intensity and short lasting or late HAS which usually follows orgasm, of more severe intensity and of longer duration, lasting hours or even days.  On the basis of the character of the headache, three subtypes have also been recognized-subtype 1 presents with a dull, tension type headache, subtype 2 with an explosive, vascular type of headache and subtype 3 occurs with alteration in posture only.  The three subtypes are however seen as different manifestations of the same illness and not distinct entities. 
| Pathophysiology|| |
The exact pathophysiology of primary HAS is not completely understood, it is however believed that there is both a vascular and a muscular basis for the headache.  Local cerebral vasospasm in the concept of Reversible Cerebral Vasoconstriction Syndrome (RCVS) has been linked with primary HAS and masturbatory orgasm.  Primary HAS with very severe headaches may be one of the manifestations of RCVS. ,,
The coexistence of HAS with exertional headaches in some individuals also suggests the possibility of pericranial muscular contraction as an additional underlying pathophysiology.  Both HAS and exertional haeadches are believed to be different expressions of the same condition and they are examples of activity related headaches with many similar characteristics.  Primary HAS has also been described more commonly in migraineurs and this may also suggest a trigeminovascular basis. , Emotional changes have been implicated as a potential trigger of primary HAS in some patients, an indication that there could also be a psychological basis for HAS. 
In HAS associated with underlying intracranial disease conditions like subarachnoid haemorrhage, alterations in cerebral haemodynamics also underlie the headaches. 
The haemodynamic and autonomic changes that occurs during sexual intercourse results in increased blood pressure, heart and respiratory rates with orgasmic muscle contraction of the perineum and upper thighs, and the increase in mean arterial blood pressure in both males and females could be as high as 45 and 35 mmHg respectively above the baseline  In addition, there is an increase in the activation of the paraventricular nucleus of the hypothalamus during orgasm.  A disturbed metabolic cerebral autoregulation as a result of a hypothalamic malfunction, has been described as the main underlying factor in HAS. 
The following have been associated with secondary HAS-some of which are life threatening:
A common denominator of all the above conditions is direct or indirect alteration in cerebral haemodynamics.
- Warning leaks (sentinel bleeds) or expansion or rupture of cerebral aneurysms
- Arteriovenous malformation (AVM)
- Dissection of major cerebral blood vessels with resultant infarctive strokes
- Severe systemic hypertension
- Drugs like sidenafil (Viagra ® ) and other PDE5 inhibitors for erectile dysfunction
- Illicit drugs like cannabis (marijuana) or cocaine or heroine
| Clinical features|| |
Headache associated with sexual activity could be mild, moderate or severe and disabling and sometimes reaching proportions that could be described as thunderclap (very severe and explosive headache that crescendos within a minute of onset), it may lasts for few minutes or may persists for several hours and days after intercourse.  HAS could also be occasional and unpredictable.  Classically it is pulsatile and bilateral.  Persisting headache several minutes or hours after sexual intercourse or alteration in the previous form of headache should prompt investigation for a secondary underlying cause of HAS. , With the primary form, there are usually no focal neurologic signs. Presence of focal neurologic deficits following an episode of HAS is indicative of an underlying cause. , HAS is a well documented herald symptom of aneurysmal subarachnoid haemorrhage and dissection of the basilar and middle cerebral arteries with resultant cerebral and brainstem infarctive strokes have been described. ,, The sinister associations of HAS may occur after several months or years of recurrent HAS and this advises that HAS should be investigated at any stage or age in both males and females to exclude any underlying cause, even if it has been recurrent and seemingly innocuous for months or years. 
| Investigations|| |
The premise for the investigation of HAS currently is to exclude any sinister or potentially life threatening cause of the headache particularly aneurysmal subarachnoid haemorrhage.  Evaluation of HAS should begin with a thorough history and characterisation of the headache preferably by a Neurologist.  The following may be relevant questions-duration and intensity of the headache, other associated symptoms, history of exertional headaches, history of hypertension and drugs and history of primary headaches like migraine or tension type headache or cluster headaches. Red flag features include headaches lasting more than a few minutes after intercourse, severe headaches, focal lateralizing signs, alteration in the characteristics of the headache, history of uncontrolled hypertension and performance enhancing drugs like sildenafil and a history of illicit drugs like cannabis, cocaine or heroin.
A thorough physical and neurologic examination should follow.
Ancillary investigations may be indicated and they include the following:
- Neuroimaging modality like cranial computed tomography or magnetic resonance imaging which may reveal mass lesions or blood in the subarachnoid space
- Magnetic resonance angiography. This may reveal aneurysms or AVMs of cerebral blood vessels. It may also reveal RCVS
- Lumbar puncture-This is indicated if neuroimaging modalities cannot exclude subarachnoid haemorrhage after at least 12 h and up to 4 weeks of the onset of headache. It becomes very useful when the patient presents few weeks after the onset of headaches. Xanthochromia in a supernatant of cerebrospinal fluid may be seen with a spectrophotometer in up to 40% of subarachnoid haemorrhage after 4 weeks of the bleed. ,
| Treatment|| |
Primary HAS responds favorably to common analgesics like indomethacin (a nonsteroidal anti-inflammatory agent), if symptoms persist for more than few minutes after intercourse. , Indomethacin has traditionally been found very useful in a unique way that is different from other nonsteroidal anti-inflammatory drugs, thereby qualifying primary HAS as an example of indomethacin responsive headache alongside primary cough and primary stabbing headache).  A dose of 25-50 mg before or after intercourse prevents or reduce the duration of HAS.  A background history of dyspepsia or peptic ulcer may warrant the addition of a proton pump inhibitor like omeprazole and where indomethacin is not tolerated, triptans like sumatriptan could be tried as an alternative drug in primary HAS.  As in exertional headaches, beta blockers like propranolol have also been found useful in the treatment of primary HAS.  HAS should be promptly investigated and any underlying cause treated. Vascular aneurysms and AVMs should be treated surgically and if reversible cerebral vasoconstriction is underlying, treatment with nimodipine (a calcium channel blocker and vasodilator) becomes very valuable.  Systemic hypertension should be optimally treated. Prophylaxis for migraine or cluster headaches like verapamil, another calcium channel blocker, may be prescribed if they are found associated with HAS.  Successful treatment with diltiazem (a calcium channel blocker), has also been reported for primary HAS.  Alcohol should be advised against and psychotherapy may be helpful if emotional disturbances are associated with it. 
| Prognosis|| |
Primary HAS has an excellent prognosis. It is however a diagnosis of exclusion. The prognosis of secondary HAS depends on the underlying cause and aneurysmal subarachnoid haemorrhage is the most dreaded.
| Conclusion|| |
The cause of HAS may range from the benign to the life threatening and only a thorough clinical and paraclinical investigation could clinch a diagnosis. Sinister outcomes could be averted if HAS is promptly evaluated. It bears reiteration therefore that HAS should be investigated at any age or stage.
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