Not Tonight, I Have a Headache?

Timothy T. Houle, PhD; Lara K. Dhingra, PhD; Thomas A. Remble, MA; Lori A. Rokicki, PhD; Donald B. Penzien, PhD


Headache. 2006;46(6):983-990. 

In This Article

Abstract and Introduction

Objective: The present study examined the relationship between the diagnosis of migraine and self-reported sexual desire.
Background: There is evidence for a complex relationship between sexual activity and headache, particularly migraine. The current headache diagnostic criteria even distinguish between several types of primary headaches associated with sexual activity.
Methods: Members of the community or students at the Illinois Institute of Technology (N = 68) were administered the Brief Headache Diagnostic Interview and the Sexual Desire Inventory (SDI). Based on the revised diagnostic criteria established by the International Headache Society (ICHD-II), participants were placed in 1 of the 2 headache diagnostic groups: migraine (n = 23) or tension-type (n = 36).
Results: Migraine subjects reported higher SDI scores, and rated their own perceived level of desire higher than those suffering from tension-type headache. The presence of the symptom "headache aggravated by routine physical activity" significantly predicted an elevated SDI score.
Conclusions: Migraine headaches and sexual desire both appear to be at least partially modulated by serotonin (5-HT). The metabolism of 5-HT has been shown to covary with the onset of a migraine attack, and migraineurs appear to have chronically low systemic 5-HT. As sexual desire also has been linked to serotonin levels, the results are consistent with the hypothesis that migraine and sexual desire both may be modulated by similar serotonergic phenomena.

"Not tonight, honey, I have a headache…" is a humorous cliché that is associated with a person's desire to avoid sexual activity. Stereotypically, in our society this excuse is linked to women, and its humor is perhaps derived from socially assumed gender differences in sex drive and the perceived role of women acting as the gatekeepers for sex. Indeed, the incompatibility of sex while suffering from a headache is intuitively valid. Yet, there is growing evidence for a complex relationship between sexual activity and headache, particularly migraine, which may greatly complicate the entire notion behind the cliché.

Sexual arousal and intercourse have been thought to cause headaches. Headaches associated with sexual activity have long been recognized,[1,2,3,4] and the current headache diagnostic criteria even distinguish between several types of primary headaches associated with sexual activity.[5] Pre-orgasmic headaches (IHS 4.4.1) are described as having a bilateral location, building in intensity with the increase of sexual arousal. Orgasmic headaches (IHS 4.4.2) are described as "explosive" headaches which occur post-orgasm. Both headache types have characteristics that are related to exertional headaches and are perhaps variants of migraine.[1,6]

Conversely, sexual activity also has been thought to relieve headaches. In an unpublished study, Couch and Bearss described that of the 70% of women in their sample (n = 82) who reported having had sexual intercourse during at least 1 migraine attack, approximately one-half (47%) experienced at least some relief from the headache following sexual intercourse (17.5% reported complete relief from the headache).[6,7] These results support the authors' previous findings from a smaller sample (n = 34) in which 21% of patients reported some relief after intercourse.[8]

Perhaps migraine and sexual desire are 2 distinct phenomena that may be related as a result of their mutual association with serotonin (5-HT). In an extensive review, Ferrari and Saxena[9] described the role that 5-HT plays in the onset, course, and termination of a migraine attack. The authors utilized many experimental studies to demonstrate that 5-HT is closely and complexly linked with the pathophysiology of migraine. It has been reported that migraineurs have chronically low systemic 5-HT[9,10] and, perhaps, this deficit is related to susceptibility to migraine.[9] Specifically, 5-HT has been implicated as having a vasotropic effect on the cardiovascular system,[11,12] and migraine headaches are commonly thought to have a strong vascular component.[9]

Sexual desire also has been linked with 5-HT. An excess of 5-HT at the hypothesized "mating center" in the midbrain has been reported to antagonize testosterone in men, decreasing libido.[13] Further, the side effects of selective serotonin reuptake inhibitors (SSRIs), such as decreased desire and anorgasmia in both men and women, have also been well documented.[14,15] While gender differences in self-reported sexual desire have also been reported with males reporting higher levels of desire than do females,[16] the relationship of sexual desire and gender to 5-HT is less clear. The specific effects of 5-HT may depend on 5-HT receptor subtypes and/or central versus peripheral effects 5-HT.[17,18] The extent to which gender differences of 5-HT levels and 5-HT receptor subtypes (and the influence of associated neuroendocrine factors) account for differences in sexual desire is unknown.

Considering this circumstantial evidence linking both migraine and sexual desire to serotonin, are the 2 phenomena actually related? Only a single study by Del Bene et al[19] could be identified examining the potential relationship between headache diagnosis and sexual desire. This study found that those suffering from headache differed from controls on several aspects of sexuality. Even though those suffering from headache reported the same frequency of dyadic sexual activity, they reported engaging in masturbation less frequently than controls. However, females suffering from headache reported more sexual fantasies than controls, while the same difference was not observed in males. Although preliminary, the Del Bene study provides important information about the relationship between headache and sexual desire. Nevertheless, the generalizability of its results may be greatly limited by its small sample size (only 8 migraineurs of each gender were assessed and compared to an equal number of controls). Further, it did not employ standardized measures to assess sexual behavior and cognitions which are difficult constructs to measure. Finally, this solitary study was conducted on an Italian population presenting unknown cultural confounds.

The present study was conducted to further examine the relationship between headache diagnosis and sexual desire. It was hypothesized that the abnormalities in the serotonergic system of migraineurs influence their sexual desire even at baseline. Based on findings that an excess of 5-HT in the midbrain is primarily inhibitory in terms of sexual desire, as well as research observing chronically low levels of systemic 5-HT in migraineurs,[1] it was predicted that migraineurs would report higher levels of sex drive than those suffering from tension-type headache (TTH). Further, based on previous research on gender differences,[16] it was also hypothesized that gender effects would be observed, with males reporting higher levels of sexual desire than females. Finally, given the findings reported by Del Bene et al,[19] we hypothesized that gender and headache diagnosis would interact such that female migraineurs' level of sexual desire will be more similar to male migraineurs than females suffering from TTH are to males suffering from TTH.


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