Synonyms: orgasmic cephalgia, orgasmic headache, coital cephalgia, sexual headache

Introduction¹

Various types of headache have been identified in association with sexual activity. These were first classified by Lance in 1974:^2,3

• Early coital cephalgia, which is usually of short duration and moderately severe. It is a tight, cramping, dull pain, often occurring bilaterally in the occipital/cervical region, which intensifies as sexual excitement increases. It is thought to relate to excessive contraction of the head and neck musculature that occurs prior to orgasm.
• Orgasmic coital cephalgia, which is severe, of abrupt onset and lasts 15 to 20 minutes. It can be in the occipital region, behind the eyes, or in a more generalised form and occurs at the point of orgasm. It may be prevented by postponing orgasm. It is the most common type of headache associated with sexual activity.⁴ It has been suggested that the cause is related to a rise in blood pressure but, since the headache persists when the blood pressure returns to normal, other factors, possibly migrainous, are involved.⁵
• Late coital cephalgia, comes on after standing and may last hours or days. It is thought to be associated with low cerebrospinal fluid pressure secondary to a dural tear following the physiological stress of coitus. It is identical to the headache seen after lumbar puncture.⁴

The pattern of headaches can be variable. Some appear suddenly, last for many months or years and stop abruptly; others occur on a regular basis for a long period of time.⁶ Attacks may be intermittent and mild, or so severe as to preclude any sexual intercourse.⁷ Amnesia can be a feature.⁸

Whilst most coital headaches are benign (primary benign cephalgia) - others are associated with significant morbidity ('malignant coital cephalgia'). Some patients have reversible cerebral vasoconstriction syndromes.⁹

Studies have shown that subarachnoid bleeding was precipitated by coitus in 3.8-12% of patients with saccular aneurysms and in 4.1% of patients with arteriovenous malformations.⁴ Thunderclap headache with orgasm, caused by basilar artery dissection, has been reported.

Classification

Primary sexual headache is included in "Other Primary Headaches" (Group 4) in the International Classification of Headache Disorders, 2nd edition (ICHD-II).⁹

Epidemiology

Little is known about the incidence but studies of neurology patients presenting with headache in France and Denmark have quoted figures of 0.21% and 1.3% respectively. These are likely to be underestimates.¹⁰ There is a 3:1 predominance of males. The age of onset peaks between 20-24 years and again between 35-44 years. A case in a boy of 12 has been reported.¹¹There appears to be a high comorbidity with migraine (25%), benign exertional headache (29%) and tension-type headache (45%). Occurrence is not dependent on specific sexual habits and most often occurs during sexual activity with the usual partner (94%) and during masturbation (35%).^1,12

Risk factors

These include obesity, kneeling position during intercourse, the degree of sexual excitement, stress, history of migraine and exertion headache and a family history of headache and occlusive arterial disease.^4,13,14 There is at least one report of familial sexual headache.¹³ Pharmacological triggers may include marijuana, amyl nitrite, amfetamines, sildenafil and some anxiolytics.^2,15

Diagnosis

The diagnosis of benign coital cephalgia is one of exclusion, having ruled out subarachnoid bleeding from a saccular aneurysm or arteriovenous malformation. Lack of accompanying symptoms such as blurred vision, vomiting or visual, sensory, or motor disturbances should identify benign headaches from those requiring further investigation.^2,6 A careful history and examination are essential. Patients suspected of having a subarachnoid haemorrhage or arteriovenous malformation should have a neurological assessment, including CT scan.⁴

Prevention

Weight reduction, increase in exercise, taking the passive role in intercourse and avoidance of drugs which act as trigger factors are all thought to be helpful.⁴

Management

Relaxation therapy and biofeedback are poorly supported by evidence but have been helpful in some patients.⁴ With regard to drug management, there are no meta-analyses but the following are supported by randomised trials or case reports:

• Propranolol - 40-240 mg a day. This can be used on a preventative basis.²
• Indometacin - 25 mg-75 mg a day can be used on an intermittent or regular basis.²
• Calcium-channel blockers (e.g. diltiazem 60 mg tds) have been helpful in some patients, particularly where cerebral vasoconstriction is the cause.¹⁶
• One case of steroid and local anaesthetic injection to the greater occipital nerve was effective in one patient.¹⁷
• One study reported a role for triptans both in the acute phase and in prophylaxis of headache associated with sexual activity.¹⁸

Prognosis

The prognosis is encouraging. In one study, out of 45 patients who had suffered from single attacks or bouts prior to baseline examination, 37 had no further attacks. Seven patients suffered from at least one further bout with an average duration of 2.1 months. One patient developed a chronic course of the disease after an episodic start. Of patients with recurrent headaches, 69% eventually resolved over three years.¹⁹

Document references

1. Frese A, Eikermann A, Frese K, et al; Headache associated with sexual activity: demography, clinical features, and comorbidity. Neurology. 2003 Sep 23;61(6):796-800. [abstract]
2. Goldstein J; Sexual aspects of headache. How sexual function relates to headaches and their causes and treatment. Postgrad Med. 2001 Jan;109(1):81-4, 87-8, 92. [abstract]
3. Lance JW; Headaches occurring during sexual intercourse. Proc Aust Assoc Neurol. 1974;11:57-60.
4. Sami HR, Couch JR; Primary headache associated with sexual activity; Neuroblog 6.17.2004
5. Porter M, Jankovic J; Benign coital cephalalgia. Differential diagnosis and treatment. Arch Neurol. 1981 Nov;38(11):710-2. [abstract]
6. Ostergaard JR, Kraft M; Benign coital headache. Cephalalgia. 1992 Dec;12(6):353-5. [abstract]
7. Delasobera BE, Osborn SR, Davis JE; Thunderclap Headache with Orgasm: A Case of Basilar Artery Dissection Associated J Emerg Med. 2009 Oct 7. [abstract]
8. Larner AJ; Transient acute neurologic sequelae of sexual activity: headache and amnesia. J Sex Med. 2008 Feb;5(2):284-8. Epub 2007 Dec 7. [abstract]
9. Wang SJ, Fuh JL; The "other" headaches: primary cough, exertion, sex, and primary stabbing Curr Pain Headache Rep. 2010 Feb;14(1):41-6. [abstract]
10. Lui F; Clinics in Neurology; Clinics in Neurology: Coital Headache Journal of the Hong Kong Medical Association Vol. 42, No. 1, 1990
11. Evers S, Peikert A, Frese A; Sexual headache in young adolescence: a case report. Headache. 2009 Sep;49(8):1234-5. Epub 2009 Jul 27. [abstract]
12. Chakravarty A; Primary headaches associated with sexual activity--some observations in Indian patients. Cephalalgia. 2006 Feb;26(2):202-7. [abstract]
13. Johns DR; Benign sexual headache within a family. Arch Neurol. 1986 Nov;43(11):1158-60. [abstract]
14. Jenkins S; Sports Science Handbook 2005
15. Alvaro LC, Iriondo I, Villaverde FJ; Sexual headache and stroke in a heavy cannabis smoker. Headache. 2002 Mar;42(3):224-6. [abstract]
16. Theeler BJ, Krasnokutsky MV, Scott BR; Exertional reversible cerebral vasoconstriction responsive to verapamil. Neurol Sci. 2010 Feb 25. [abstract]
17. Selekler M, Kutlu A, Dundar G; Orgasmic headache responsive to greater occipital nerve blockade. Headache. 2009 Jan;49(1):130-1. Epub 2008 Sep 26. [abstract]
18. Frese A, Gantenbein A, Marziniak M, et al; Triptans in orgasmic headache. Cephalalgia. 2006 Dec;26(12):1458-61. [abstract]
19. Frese A, Rahmann A, Gregor N, et al; Headache associated with sexual activity: prognosis and treatment options. Cephalalgia. 2007 Nov;27(11):1265-70. Epub 2007 Oct 5. [abstract]

Acknowledgements