Randolph Warren Evans, MD

Disclosures

February 06, 2001

Question

What is the likely etiology of recent onset of coital headaches in an otherwise healthy 42-year-old man? Headaches begin at orgasm, are extremely intense, and localized near the top/center of the head. He experiences no aura, photophobia, or other neurologic symptoms. The headache resolves slowly over the next 2-3 days with a gradual reduction in intensity, and less localization.

The patient reports no history of head trauma. A thorough occupational/recreational history reveals no exposures to chemical agents, solvents, etc. The patient has suffered 3 episodes in the last 3 weeks. He has self-medicated with aspirin, Tylenol, and ibuprofen to no avail. He takes no other medications, is physically fit, and the physical and neurologic exam is without findings.

Response from Randolph Warren Evans, MD

Clinical Associate Professor in the Department of Neurology at the University of Texas at Houston Medical School and Clinical Associate Professor in the Department of Family and Community Medicine at Baylor College of Medicine.

Headaches can be triggered by coughing, exertion, and sexual activity.[1,2,3] The lifetime prevalence of benign cough headache, benign exertional headache, and headache associated with sexual activity is 1% for each.[4] All 3 headache types occur more often in men than women.

Furthermore, 3 types of headache are precipitated by sexual excitement (masturbation or coitus), all bilateral at onset, prevented or eased by ceasing sexual activity before orgasm, and not associated with any intracranial disorder such as aneurysm. The dull type is a dull ache in the head and neck that intensifies as sexual excitement increases. The explosive type is a sudden severe headache occurring at orgasm. The postural type is a postural headache resembling that of low CSF pressure, and develops after coitus. The patient in this case fits the explosive type profile.

Testing such as brain MRI with intracranial MRA should be considered, although the yield would be expected to be low in view of the history of 3 identical headaches. However, caution is advised when diagnosing the first sex headache since sexual activity is the precipitant of up to 12% of ruptured saccular aneurysms and 4% of patients with SAH due to bleeding AVM's.[5] Rarely, pheochromocytomas can present with paroxysmal hypertension precipitated by sexual activity. Posterior fossa pathology such as neoplasm or Chiari malformation is more commonly associated with secondary cough and exertional headaches than sexual headaches.

In a study of patients with the explosive type of headache, those who stopped sexual activity before orgasm experienced a headache duration of 5 minutes to 2 hours.[6] Those who proceeded to orgasm had a severe headache for 3 minutes to 4 hours and a milder headache for 1-48 hours afterwards. Forty percent of patients with the explosive type also suffer exertional headache.[7] A personal or family history of migraine is common in sexual headaches. These headaches occur more frequently when the person tries to achieve more than 1 orgasm after a brief interval. Sildenafil can cause headaches in 10% of users.[8] Extracephalic pain can be due to masturbation. Severe paroxysmal ice pick-like pains referred to the neck have been described in a patient with compressive spondylitic cervical myelopathy, and referred to the groin and genitalia in another patient with a tethered cord.[9]

The natural history of the benign explosive type of sexual headaches is variable. In a study of 26 patients, the headaches went away in 50% after 6 weeks to 6 months but recurred in 50% after remissions of up to 6 years.[10] Headaches may be prevented in some patients by weight loss, an exercise program, a more passive role during intercourse, variation in posture, limitation of additional sexual activity on the same day, and medications.[11] Indomethacin, ergotamine tartrate, methylsergide, or naratriptan taken before sexual activity have been reported as preventive.[5] Propranolol (40-200 mg total per day) and diltiazem (60 mg 3 times daily)[12] can be given as a daily preventive if this headache type occurs frequently.

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