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) (09), 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 (19).
Forty percent of patients with sexual headaches also experience benign exertional headache (47; 13). A personal or family history of migraine is common but not absolute (26; 47; 38; 13). 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 (25; 26).
(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 (23; 38). Although the etiology is unknown, it has been postulated to be caused by the increased blood pressure that occurs during orgasm (25; 26). 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 (35; 26; 28; 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 (21). 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 (22) (Table 1).
Table 1. Diagnostic Criteria for Primary Headache Associated with Sexual Activity (ICHD-3)
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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. |
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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: |
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1. increasing in intensity with increasing sexual excitement
2. abrupt explosive intensity just before or with orgasm |
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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 (37).
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; 38). 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 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.
