4.6: Headache associated with sexual activity

This headache type is known as coital headache or orgasmic headache. Although anxiety associated with illicit sexual encounters may, at times, be accountable for headache, sudden excruciating, throbbing, occipital headache, usually occurring just before or after orgasm, is not likely to have a psychogenic mechanism and represents coital migraine. (Raskin, 1988) Wolff (1963) was the first to recognize that a benign headache syndrome could arise in association with sexual activity. In some patients, the headache occurs regularly with sexual activity, but in most it develops unpredictably and infrequently, correlates poorly with the level of sexual excitement, and the physical exertion is expended at these times. Men seem to be effected much more commonly than women (4:1 ratio); the age at onset ranges from the second through the sixth decades of life with a mean age of 40 years. This topic has been reviewed by Braun and Klawans (1986), Johns (1986).

Three different patterns of headache may occur in association with sexual activity, including masturbation. The most common begins at or shortly before orgasm, is of high intensity, usually frontal or occipital in location, and is explosive or throbbing in quality. It can persist for minutes to a few hours and a milder dull headache may linger for as long as 48 hours (Johns 1986). Selwyn (1985) reported that some patients have observed that headache could be avoided if the neck was kept lower than the body during coitus.

Lance (1976) performed lateral carotid angiography on 7 of his 21 patients and vertebral angiography on 2 without documenting an abnormality. Rarely an unruptured aneurysm may result in a headache syndrome during coitus that is indistinguishable from benign coital headache (Day and Raskin, 1986). The presence of vomiting or severe headache lasting more than 24 hours definitely calls for neuroimaging studies probably including four-vessel cerebral angiography.

A second headache syndrome which is believed to be dependent on facial and neck muscle contraction begins earlier during the course of making love and is occipital or diffuse in character becoming most severe at orgasm. The least common headache syndrome associated with sexual activity is a postural suboccipital headache markedly accentuated when the patient is upright and associated with nausea and vomiting. Paulson and Klawans (1974) documented low CSF pressure in two cases. Headache persists for 2 to 3 weeks and spontaneously stops. Raskin (1988) believes that the coital headache syndrome resembles that of a pheochromocytoma, in that a similar vascular pressor mechanism may be responsible. Because of the variation in physical energy expended and variations in blood pressures at the time of occurrence of this benign headache none of the phenomenon are well-explained by any one biological variable.

Propranolol and indomethacin are recommended as considerations for therapy. I have found that verapamil 240 mg sustained release has completely blocked the syndrome in 2 patients.

 

We have reported a patient who was originally believed to have coital migraine but had other signs and symptoms which alerted us to the possibility that it was not this benign type of headache.  The manuscript is entitled "Not-so-Benign Orgasmic Migraine" and has been placed on line.
 

 

 

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