Orgasmic Cephalgia

Synonyms: Orgasmic Headache, Coital Cephalgia, Thunderclap Headache, Sexual Headache

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.¹ There is a 3:1 predominance of males. The age of onset peaks between 20-24 years, and again between 35- 44 years. There 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 occurred during sexual activity with the usual partner (94%) and during masturbation (35%).^2,3

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.^4,5,6 There is at least one report of familial sexual headache.⁵ Pharmacological triggers may include marijuana, amyl nitrite, amphetamines, sildenafil and some anxiolytics.^7,8

Various types of headache have been identified in association with sexual activity. These were first classified by Lance in 1974:^7,9

• 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.¹⁰
• 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.¹¹ Attacks may be intermittent and mild, or so severe as to preclude any sexual intercourse.⁴

Whilst most coital headaches are benign (primary benign cephalgia) - others are associated with significant morbidity ('malignant coital cephalgia'). 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

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.^7,11 A careful history and examination is essential. Patients suspected of having a subarachnoid haemorrhage or arteriovenous malformation should have a neurological assessment, including CT scan.⁴

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

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 preventive basis.⁷
• Indometacin - 25 mg-75 mg a day can be used on an intermittent or regular basis.⁷
• Calcium channel blockers (e.g. diltiazem 60 mg t.d.s.) have been helpful in some patients.

The prognosis is encouraging. In one study, 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.¹²