Primary Headache Associated with Sexual Activity. 2023
Dr. James W. Lance from Sydney, Australia made the following comment in 1974 in an article in the Proceedings of the Australian Association of Neurologists entitled, “Headaches occurring during sexual activity.”
“Since various foods and wines are often incriminated as sources of headache, it seemed to be only a matter of time before sexual intercourse was added to the list of pleasurable activities which may be responsible for headache, the most common of kill-joys.”
Primary Headache Associated with Sexual Activity occurs during sexual relations, or especially at orgasm. It is a daunting neurologic problem. Headache with sexual relations happens to many normal migraine patients who have nothing wrong with them, except to have unfortunately inherited migraine.
The second International Classification of Headache Disorders, (ICHD 2), called these syndromes “Orgasmic” or “Preorgasmic” Headache.
Rare persons may have a disturbing “Thunderclap Headache” at orgasm indicating nothing, or rarely something severely wrong like a ruptured cerebral aneurysm.
Read my article, “Primary Thunderclap Headache,” on my website, www.doctormigraine.com.
So what is it, this sexual related headache—something severe and worrisome or just another part of the migraine experience? These type of headaches usually need to be carefully sorted out with neurologic examination and tests such as a spinal tap, CAT scan, or MRI scan of the brain.
Read my article, “What is Migraine?” on my website, www.doctormigraine.com.
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This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, migraine textbook author, podcaster, YouTube video producer, and blogger.
Primary Headache Associated with Sexual Activity is a type of headache that starts and suddenly becomes intense at orgasm, in the absence of any intracranial disorder.
ICHD 3 states there should be:
At least two episodes of pain in the head and/or neck fulfilling criteria 1-4:
Brought on by and occurring only during sexual activity
Either or both of the following:
increasing in intensity with increasing sexual excitement
abrupt explosive intensity just before or with orgasm
Lasting from 1 minute to 24 hours with severe intensity and/or up to 72 hours with mild intensity
Not better accounted for by another ICHD-3 diagnosis.
What this condition does not have.
Primary headache associated with sexual activity does not come with loss of consciousness, vomiting, or visual, sensory, or motor symptoms. At the time of the first attack there must be exclusion or subarachnoid hemorrhage, intra- and extracranial arterial dissection, and reversible cerebral vasoconstriction syndrome (RCVS).
Previous names for this condition.
This condition has previously been referred to as sexual headache, benign vascular sexual headache, coital cephalalgia, coital headache, intercourse headache, (pre)orgasmic cephalalgia, and (pre)orgasmic headache.
Further definition of Primary Headache Associated with Sexual Headache.
Primary Headache Associated with Sexual Activity is an uncommon type of headache that may occur either as a primary headache, like a migraine, or as a headache caused by a more serious process such as a ruptured cerebral aneurysm.
Read my article, “Migraine with Aura,” on my website, www.doctormigraine.com.
“Primary” refers to a benign medical problem, like “primary hypertension.” The primary headache type mentioned here is migraine.
Related questions
What is the cause (pathophysiology) of these headaches?
The cause of primary headache associated with sexual activity is unknown. Headaches of this type are difficult to study because they are rare and present clinically in different ways.
An investigator proposed that pre-orgasmic headaches are caused by excessive contraction of neck and jaw muscles during sexual activity and that they might be avoided by conscious relaxation of these muscles during intercourse.
Headaches at orgasm have been attributed to rapid increases in blood pressure and heart rate that occur during orgasm. It has been suggested that orgasmic headache could be a migraine variant and many cases of migraine have been found in case series of patients with primary headache associated with sexual activity.
In spite of the migraine links patients with this type presentation should still be thoroughly evaluated.
There also may be a link of primary headache associated with sexual activity and exertional headache. One study of 45 patients with primary sexual headache found that 40 percent had also experienced primary exertional headache on at least one occasion.
What is the description of primary headache associated with sexual activity?
A sudden, severe, often times “explosive” headache that occurs at orgasm is a very alarming symptom. The term “sudden” may need further explanation.
These headaches come on “in seconds, like a flash, like a bolt from the blue, like I was hit on the head with a hammer.”
Kaboom!
Liu stated about this type of headache, “They all have a rather unpredictable clinical course. They may occur suddenly, continue for some time and then end abruptly.”
Ostergaard put the syndrome in a more optimistic perspective when he stated, “Frequently, however, it is a troublesome but rather benign kind of headache in which no serious underlying condition can be found.”
“Not tonight; I have a headache.” is a common humorous cliché reflecting socially assumed gender differences in sex drive and the perceived role of women regarding controlling and sometimes avoiding sexual activity which exists in modern culture.
The phrase, reportedly attributed to Napoleon Bonaparte’s wife, is stereotypically used by wives as an excuse to avoid sexual relations with their husbands. Since migraine is a common disabling condition, the medical justification of avoiding sexual relations during a bad headache is certainly justified.
Not tonight, honey, I have a headache.
However, Couch and Bearss reported in 1987 that some individuals have noted relief from migraine headache with sexual activity and orgasm.
These researchers noted that “Traditionally, it has been thought that sexual activity makes migraine worse.” They reported 31 patients, 29 females and 2 males, who had intermittent migraine.
When queried regarding engagement in sexual activity during a migraine headache, 7 women had never attempted sexual relations during a migraine headache, 12 indicated that it did not affect their headaches either way, and 3 women felt it made them worse.
Seven women indicated that their headaches improved with sexual activity: 2 experienced complete relief; 3 noted significant relief; and 2 noted slight improvement. The two males reported that they had never attempted sexual activity during a migraine.
Recent studies have shown that up to 40% of all cases run a chronic course over more than a year.
Some patients experience only one attack of 4.3 Primary headache associated with sexual activity during their lives; they should be diagnosed as 4.3.1 Probable primary headache associated with sexual activity.
For further research on this headache type, it is recommended to include only patients with at least two attacks.
Epidemiological research has further shown that Primary headache associated with sexual activity can occur at any sexually active age, is more prevalent in males than in females (ratios range from 1.2:1 to 3:1), occurs independently of the type of sexual activity, is not accompanied by autonomic or vegetative symptoms in most cases, is bilateral in two-thirds and unilateral in one-third of cases and is diffuse or occipitally localized in 80% of cases. Attack frequency of Primary headache associated with sexual activity should always be related to the frequency of sexual activity.
What are other features of primary headache associated with sexual activity?
The first occurrence of headache associated with sexual activity requires thorough neurological examination, CAT or MRI scan, and spinal fluid exam to rule out serious problems such as subarachnoid hemorrhage secondary to aneurysmal or AVM rupture or arterial dissection.
Subarachnoid hemorrhage has been reported to occur during intercourse in from 3.8% to 12% of aneurysms and in 4.1% of AV malformations.
Other organic considerations include intracerebral hemorrhage, cerebral venous thrombosis, un-ruptured vascular malformation (which is predominantly aneurysm), CNS angiitis, reversible benign CNS angiopathy, pituitary apoplexy, colloid cyst of the third ventricle, CSF hypotension, acute sinusitis (especially with barotrauma), pheochromacytoma, Arnold Chiari Malformation, and posterior fossa tumors.
What is the relationship to other headache types and exertion?
The diagnosis of either primary exertional headache (headache brought on by exercise, such as weight lifting) or migraine is reported in about half of the cases. Can headaches like this be related to physical exertion? Hippocrates certainly thought so. He wrote:
Going to 300 pounds, man!
“one should be able to recognize those who have headaches from gymnastic exercises, or running, or walking, or hunting, or any other reasonable labor, or from immoderate venery.” (excessive sexual activity).
Silbert found that 18 of 45 patients with sexually related headache had also experienced headaches on exertion.
Ostergaard, et al, in 1992 reported in the British Medical Journal on 32 patients collected through 1978-1991 in an article entitled “Natural course of benign coital headache.”
He followed his patients for 6 months to 14 years with a median of 6 years. Five of Ostergaard’s 12 patients had migraine without aura and 7 had tension headache.
Frese, et al, in 2003 stated, “There was a high comorbidity with migraine (25%), benign exertional headache (29%), and tension-type headache (45%).”
Lance stated in an editorial entitled “When sex is a headache” in the British Medical Journal in 1991 that:
“Such headaches may well be precipitated by an acute pressor response--during orgasm systolic blood pressure increases by 40-100 mm Hg and diastolic pressure increases by 20-50 mm Hg.”
Too high!
Queiroz wrote in 2001 that the headaches shared the Valsalva maneuver as a common pathophysiologic mechanism.
What is the literature review of primary headache associated with sexual activity?
Wolff described three women who suffered sudden, severe pain in the head at the beginning of orgasm, the headache lasting from several minutes to several days.
Fisher briefly touched on the subject while discussing headaches caused by cerebrovascular disease. He reported three patients who experienced headache during intercourse, two of whom had intracranial hemorrhage.
Not now! I have a freaking headache. Turn out the light!
Lance describes the evolution of knowledge about the subject:
Correspondence in the British Medical Journal (1973) was recently triggered by an answer given in the section ‘Any Questions?’ to an enquiry headed ‘Severe headache accompanying orgasm’. The question described a woman of 50 who for the previous few months had experienced ‘a severe gripping pain which seems to encase her whole head’ associated with orgasm. It lasted for about ten minutes, after which she dropped off to sleep. The questioner asked, ‘Is this a recognized phenomenon?’
The printed answer began ‘This is not a recognized phenomenon’ and concluded ‘It might be wise therefore to assume that something is happening during orgasm which is raising a presently subclinical disorder to a clinically apparent level.’
In response to this, a number of correspondents wrote to mention individual cases of apparently benign coital headaches and Martin (1973) described six male patients, all of whom were subject to sudden severe headache towards the end of intercourse, commonly bilateral, affecting the back of the head more often than the front and lasting 10-60 minutes, although more prolonged attacks were recorded. Three patients had a past history of migraine. All had remained in good health. Martin quoted Kritz who had reported 25 cases, all male, in ‘Ceskoslovenska Neurologic.’
Lance mentioned having seen such cases in 1969 and Martin quotes personal communication from Williams (1970) who called the condition ‘Coital Cephalalgia.’
Kriz in 1970 reported 51 patients with neurological complications occurring during sexual intercourse. Twenty-four of Kriz’ patients had only brief headaches and nothing else but 4 of his patients had intracranial hemorrhages and 10 suffered ischemic cerebral events during sexual relations. Kriz stated that 8 of his patients avoided intercourse altogether, while another 10 had to “become more passive partners.”
Martin in 1974 writing in the Irish Journal of Medical Science on “Headache during sexual intercourse (coital cephalalgia)” presented “Six examples of a benign syndrome of recurrent headache during sexual intercourse…” Martin’s report of Case 1 follows:
An engineer, aged 42, referred because of migraine, gave an account of other headaches which came on during sexual intercourse. The first occurred two weeks after marriage and was followed by two others in the next month. In each instance the headache came on abruptly at the onset of orgasm. It was at the back of the neck, spreading to the vertex and was bilateral. On two occasions it lasted for 10 minutes, once for an hour. There was no nausea or vomiting. Restraint in intercourse was, he thought, of prophylactic value.
“I just can’t ….”
He was an anxious, obsessional man and was unhappy in his occupation. He had felt run down and had been taking a yeast extract tonic…Followed up a year later, he still had occasional headache during intercourse; sometimes this was accompanied by palpitation and tremor of the hands and, possibly, pallor.
Lance in 1974 reported 7 cases and wrote in his summary:
Seven patients who experienced headache immediately preceding or during sexual orgasm are described. No evidence of any structural lesion was obtained on clinical examination or investigation, including cerebral angiography in 4 of the 7 patients…The syndrome appears to be a benign condition in many instances.
Case 2 of Lance’s 1974 article follows:
A woman aged 26 complained of a sudden occipital headache at the time of orgasm on two occasions. The headache was intense and gripping in quality, developing instantaneously ‘like an explosion’ or ‘like a steel spring snapping.’ It remained severe for 10 minutes or so then subsided over an hour. She had experienced a similar headache three times before but precipitating factors were not recorded in the history. There was a past history and family history of migraine headache, but these headaches had been frontal in site and different in character. Examination was normal. Her blood-pressure was 140/80 mm Hg. An electroencephalogram, bilateral carotid angiogram and pnemoencephalogram were normal.
Paulson and Klawans in 1974 in an article entitled ‘Benign Orgasmic Cephalgia’ described a postural headache resembling that of low CSF pressure developing after coitus and likely related to a dural tear during intercourse. The report of their case 1 follows:
This thirty-two year old army major developed acute sub-occipital pain during intercourse and was seen in consultation one day later. His severe headache was strictly limited to the times when he was in an upright position. Invariably within five minutes after lying prone the headache subsided, but when he rose again the headache soon returned and was associated with dizziness and nausea. There was prior history of migraine.
Neurologic and general physical examination were normal, as were both the brain scan and EEG. Lumbar puncture was entirely normal except for a CSF pressure of less than 20 mm. Repeat lumbar puncture one day later revealed a pressure of 10 mm. Bilateral carotid arteriograms were normal. The headache, which continued to occur only in the upright posture, slowly but completely subsided over the next three weeks.
The authors stated that, “In our patients it is possible that a rent in the spinal fluid space occurred or was widened during the physiologic stress of coitus.” They divided their patients into three with low spinal fluid pressure and eleven other patients with ‘Benign Orgasmic Cephalgia.’
ICHD-1 in 1988 had three types of primary headache associated with sexual activity: the dull aching leading up to orgasm type, the explosive at orgasm variety, and headache related to dural tear and CSF drain. ICDH-II dropped the dural tear variety which is really a symptomatic headache under the heading primary headache associated with sexual activity and kept 4.4.1
Preorgasmic headache (dull ache) and Orgasmic headache.
Lance in an article in 1976 described twenty-one patients “where no organic change can be demonstrated, analogous to benign cough headache and benign exertional headache.” He noted two varieties of headache:
one “developing as sexual excitement mounted had the characteristics of muscle contraction headache. The second, severe, throbbing or 'explosive' in character, occurring at the time of orgasm, was presumably of vascular origin associated with a hyperdynamic circulatory state.”
Lance pointed out that the headaches were similar to those found with exacerbations of pheochromacytoma.
Lance in his review in the British Medical Journal in 1991 “When sex is a headache,” added the following statement below the title: “Not funny but usually not serious.” In this BMJ editorial Dr. Lance reinforced the previous statement regarding a benign outcome by Ostergaard:
Fortunately, most headaches associated with sexual excitement do not have any sinister underlying cause, and the benign forms have a characteristic pattern that enables diagnosis in most instances.
Dr. Lance also stated in his editorial:
Benign sex headache has been reported in patients from 18 to 58 years of age, more commonly in men than women. Capricious in its appearance, it mysteriously develops on some occasions but not others, without any obvious change in sexual technique. It more commonly occurs when the subject is tired, under stress, or attempting intercourse for the second or third time in close succession. Sometimes the severe orgasmic headache may be preceded by a dull occipital ache, in which case the subject should desist on that occasion.
Fress, et al, wrote in 2003 in Neurology about “Headache associated with sexual activity. Demography, clinical features, and comorbidity.” They identified 51 patients between 1996 and 2001. The mean age at onset was 39.2 years with a clear male preponderance of 2.9:1. Two age peaks were noted, one between 20-24 years old and the second between 35-44. Eleven patients had the “dull” subtype while 40 had the “explosive” type. Frese found “There was a high comorbidity with migraine (25%), benign exertional headache (29%), and tension-type headache (45%).”
Frese, et al, wrote a follow up article in 2007 on “Headache associated with sexual activity: prognosis and treatment options.” They reported 60 patients between 1996 and 2004 who were followed between 2003 and 2006 at least 12 months after the first interview. On average, the second interview was conducted 35.9 months after the first exam. Thirty-seven out of forty-five patients had only a single attack and no more. Seven others had at least one further headache at an average of 2.1 months later. Episodic headache with sexual activity (HAS) occurred in about three-quarters and chronic HSA in approximately one-quarter of patients. Of 15 patients with chronic attacks on first exam, 7 went into remission and 5 had continued attacks. Nine out of ten of their patients got good results with Indomethacin while fifteen out of eighteen received good results with Beta blockers.
Incidence of primary headache associated with sexual activity.
The incidence of such a headache, coming as it does with sexual relations, is very difficult to ascertain as most patients do not usually talk about this.
A French neurologic clinic reported in 1980 an incidence of 0.21% of benign headache related to sexual activity among 3800 patients seen for headache.
Kraft in 1979 reported an incidence of 1.3% in a Danish group among 460 neurology patients.
Precipitating factors
Fatigue, second or third orgasm during a single tryst, extramarital affairs, or exotic sexual habits may set off these headaches, although Frese, et al, stated in 2005:
“In fact, the vast majority of patients develop their headaches with their usual partner or during masturbation. The risk does not seem to increase when the partner or setting changes.” Contributing factors are chronic hypertension, obesity, poor physical condition, and psychosocial stress.
Duration of headache
Ostergaard, et al, stated in 1992:
“In all patients the headaches were very intense for 5 to 15 minutes, and in 4 patients the symptoms then disappeared and did not recur. In 22 patients the headache declined over 1 to 24 hours and recurred at subsequent attempts at sexual intercourse, performed within a period of up to six weeks. In 4 patients this period lasted 3 to 6 months. Thirteen patients experienced only one headache or one cluster of coital headaches whereas in 9 men and 4 women the coital headache pattern reappeared after a headache free period for up to 10 years. Six of these patients had more than 3 recurrent clusters.”
Frese, et al, in 2005 found that the duration of the pain “varies widely.” The median duration of pain was 30 minutes with most severe pain lasting less than 4 hours.
Headache description
Frese, et al, in 2003 found 11 patients with the dull type and 40 with the explosive type. They found that, “The pain was predominantly bilateral (67%), and diffuse or occipital (76%). The quality was nearly equally distributed among dull, throbbing, and stabbing.” Frese, et al, stated in 2005 in a review article for the journal Practical Neurology:
Pain is occipital or diffuse in three-quarters of the patients, bilateral in two-thirds and unilateral in one-third. The quality is dull in about one-half, throbbing in one-half, and stabbing in about one-half of the patients (patients could give more than one quality).
Associated symptoms
Accompanying symptoms such as nausea and dizziness are rare but do occur.
However, severe or focal neurologic symptoms such as vomiting, decreased level of consciousness, a stiff neck, hemiparesis or hemisensory symptoms, visual changes, a seizure, or severe pain for more than 24 hours are not the features of primary headache associated with sexual activity and require immediate diagnostic workup.
Lundberg and Osterman in an article in Headache in 1974 entitled “The benign and malignant forms of orgasmic cephalalgia” reported sexual intercourse as the precipitating factor in 6 of 50 cases of subarachnoid hemorrhage.
Prevention and treatment
Headaches related to sexual activity may be prevented in some patients by weight loss, an exercise program, a more passive role during sexual relations, variation in posture, limitation of additional sexual activity on the same day, and by medication.
Many patients found some good effect for both the dull and explosive types by cessation of sexual activity at onset of headache and deferring relations to another time. Some patients may recognize mild headache before sexual activity begins and then do well by delaying sexual contact until later.
Acute therapy migraine drugs have been used before sexual relations as preventive and this includes Indomethacin (25-100 mg) given 30-60 minutes before sexual activity and triptans.
For frequent occurrences of this headache type Inderal (propanalol) (60-240 mg) or Cardiazem, Tiazac (diltiazem) 60 mg tid or long acting 180 mg qd may be tried. It seems reasonable to try other migraine preventive drugs such as amitriptyline, topiramate, valproic acid, or even one of the new CGRP antibody drugs such as Ajovy, Emgality, or Aimovig, but there is no confirmatory data on these drugs at this time.
Frese found that 2 out of 3 patients using triptans as short-term prophylaxis had a good response on several occasions. They stated:
In patients who chose to predict their sexual activity, short-term prophylaxis with oral triptans 30 minutes before sexual activity might be a therapeutic option in those not responsive to or not tolerating indomethacin.
Bottom line-Orgasmic related headaches are usually benign, but should be worked up with neurologic testing for the first attack.
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Britt Talley Daniel MD
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