Michael Eller; Peter J Goadsby


Expert Rev Neurother. 2013;13(3):263-273. 

In This Article

Cough, Exertional & Sex Headache

Three of the more common headache phenotypes not discussed above include sex headache, cough headache and exertional headache, which are described as primary disorders if no underlying lesion is found.[5] Cough headache is typically bilateral, and is often maximal over the occiput when secondary. It tends to occur in older men, and is commonly associated with maneuvers that increase intrathoracic pressure, such as straining at stool or lifting a heavy object. An MRI brain scan with paramagnetic contrast is especially indicated if these are accompanied by neurological symptoms such as vertigo and nausea.[75,76] In one series of 83 consecutive cough-headache patients from a headache clinic, representing 1.2% of all patients over a period of 8 years, had a mean age of 61.5 years. Of the nine patients with significant lesion on MRI, six were located in the posterior fossa and two consisted of a Chiari type 1 malformation.[77] In a separate series, almost 60% of the patients were found to have a secondary cause of their cough headache – usually a Chiari type 1 malformation.[75]

Headache associated with sexual activity has two common phenotypes: type 1 consists of a slowly building holocephalic pain, termed preorgasmic headache in the IHS classification, while type 2, or orgasmic headache, presents with an apoplectic headache associated with orgasm – the first episode of which will require a work-up to exclude SAH, which can present during sexual activity up to 11% of the time.[5,78] Migraine is comorbid in around a quarter of patients, as is exertional headache. This latter condition is characterized by bilateral pulsating headache that only occurs during or immediately after exercise,[79] and must be distinguished from referred pain related to myocardial ischemia.[80] In this set of patients, careful attention to a thorough systems review is mandatory. Patients with sex headache and exertional headache require an MRI brain scan.