INTRODUCTION — Headache associated with sexual activity is one of the uncommon headache syndromes that occurs in the setting of a specific recurring trigger. Symptom onset may be gradual during sexual activity or sudden at the time of orgasm. Other terms used to describe headache associated with sexual activity include:
●Sexual headache
●Benign vascular sexual headache
●Coital cephalalgia
●Coital headache
●Intercourse headache
●Pre-orgasmic or orgasmic cephalalgia
●Pre-orgasmic or orgasmic headache
This topic will discuss primary headache associated with sexual activity. Other headache disorders that occur in the setting of a triggering stimulus are discussed separately.
●(See "Exercise (exertional) headache".)
●(See "Primary cough headache".)
●(See "Cold stimulus headache".)
●(See "Hypnic headache".)
PATHOPHYSIOLOGY — The causes of primary headache associated with sexual activity are unknown, and the proposed pathophysiological mechanisms are largely speculative. Benign sexual headaches are difficult to study because of their relative rarity and variable pre-orgasmic and orgasmic clinical presentations. (See 'Clinical variability' below.)
Pre-orgasmic headaches have been proposed to arise from excessive contraction of neck and jaw muscles during sexual activity and might be avoided by conscious relaxation of these muscles during intercourse [1]. This possibility is supported by the reported association between sexual headache and exertional headache [2-4]. In one retrospective study of 45 patients with primary sexual headache, 40 percent had also experienced primary exertional headache on at least one occasion [2]. Presumably, physical exertion associated with sexual activity can be one of the factors that precipitate exertional headache in those who are predisposed. (See "Exercise (exertional) headache".)
Orgasmic headaches have been attributed to rapid increases in blood pressure and heart rate that occur during orgasm [1,5]. Trigeminovascular activation may cause vasodilation due to release of inflammatory neuropeptides, leading to cerebrovascular dysregulation and head pain, similar to proposed mechanisms in migraine [6]. (See "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults", section on 'Trigeminovascular system'.)
Some authors suggest that benign sexual headache should be considered a variant of migraine caused by hemodynamic shifts during orgasm [7-9]. Although many of the patients in reported case series of sexual headache also have a history of migraine [10], the high prevalence of migraine might result in co-occurrence of the two disorders. Additional data are warranted to better assess the underlying causes and relationship between these two disorders.
EPIDEMIOLOGY — Primary headache associated with sexual activity is rare, but its exact prevalence and incidence is unknown. One Danish population-based study found that the lifetime prevalence of sexual headache was 1 percent [11]. The prevalence may be underreported due to the brevity of symptoms and patient reluctance to discuss sexual activities.
The male to female ratio for primary headache associated with sexual activity is approximately 3:1 [12,13]. The mean age of onset is 37 to 39 years in case series [12,14]. Other reports indicate that headache associated with sexual activity can present at any sexually active age [15-17].
Other primary headache syndromes are common in patients with sexual headache, with one study reporting high rates of comorbid migraine (25 percent), exertional headache (29 percent), and tension-type headache (45 percent) [12].
CLINICAL FEATURES — The onset of headache with sexual activity characterizes the syndrome. Symptoms may occur with sexual intercourse or masturbation and may recur with subsequent sexual activity [6,12].
Head pain — Headache associated with sexual activity is bilateral in approximately two-thirds of patients and unilateral in one-third [17]. The localization is typically occipital or diffuse. The pain may be pressure-like or throbbing and can vary in peak intensity from mild to severe. Severe symptoms are often brief, lasting several minutes in most patients, but a milder headache may persist for 24 up to 72 hours [6,14,17].
Clinical variability — Headache associated with sexual activity has traditionally been divided into two types, pre-orgasmic and orgasmic, each with somewhat distinct clinical features:
●Pre-orgasmic headache – This "dull type" typically features pressure-like or aching pain that appears during sexual activity and gradually increases with mounting sexual excitement. Patients may note increased contraction in neck and jaw muscles along with the headache. Symptoms are often very brief. In one series of 21 patients, the sexual headaches persisted for about 30 minutes on average with a range from 1 to 180 minutes [1]. Less than a third of the primary headaches associated with sexual activity occur as the pre-orgasmic type [6,12].
●Orgasmic headache – This headache may be called the "explosive type," characterized by a sudden onset of severe head pain that occurs just prior to or at the moment of orgasm and followed by severe throbbing head pain. Orgasmic headache may generalize rapidly to involve the entire head. The severe pain often lasts for <15 minutes, but the subsequent throbbing head pain often persists for several hours [6]. Orgasmic headache accounts for up to 70 percent of primary headache associated with sexual activity [1,2,7].
Sudden-onset headache may also be due to several secondary causes, including subarachnoid hemorrhage, reversible cerebral vasoconstriction syndrome, and other conditions. (See 'Differential diagnosis' below.)
Despite differences in clinical description of the two subtypes, primary headache associated with sexual activity appears to be a single entity with variable presentations [12,17]. Both types of headaches are characterized by very brief episodes of head pain with triggering onset restricted to sexual activity. In one retrospective study of 51 patients with primary headache associated with sexual activity, the location, character, and duration of pain were similar among 11 patients with pre-orgasmic and 40 patients with orgasmic headache [12]. The two subtypes differed only in time of onset; the median onset of the dull subtype was 150 seconds before orgasm, while the median onset of the explosive subtype was exactly at orgasm.
Sexual headaches may be unpredictable and are not necessarily precipitated with every sexual encounter [1,7].
Associated symptoms — Severe headaches associated with sexual activity may be associated with nausea and vomiting. Cranial autonomic symptoms do not typically occur with the headache.
EVALUATION AND DIAGNOSIS — The diagnosis of primary headache associated with sexual activity is suspected when characteristic headache symptoms occur during sexual activity. The diagnosis requires the exclusion of subarachnoid hemorrhage (SAH) and other secondary causes.
Diagnostic criteria — The diagnostic criteria for primary headache associated with sexual activity from the International Classification of Headache Disorders, 3rd edition (ICHD-3) are as follows [17]:
●(A) At least two episodes of pain in the head and/or neck fulfilling all the criteria below
●(B) Brought on by and occurring only during sexual activity
●(C) Either or both of the following:
•Increasing in intensity with increasing sexual excitement
•Abrupt explosive intensity just before or with orgasm
●(D) Lasting from 1 minute to 24 hours with severe intensity and/or up to 72 hours with mild intensity
●(E) Not better accounted for by another ICHD-3 diagnosis
Probable primary headache associated with sexual activity is diagnosed if there is only one episode fulfilling criteria B through D or if there are at least two headaches fulfilling criterion B and either (but not both) of criteria C and D [17].
Our approach — Patients reporting sudden-onset severe symptoms, including those with orgasmic onset of symptoms, should be evaluated urgently SAH and other acute conditions that may present with thunderclap headache (algorithm 1). (See 'Evaluation for subarachnoid hemorrhage for patients with orgasmic headache symptoms' below.)
Once urgent evaluation excludes SAH, further evaluation to exclude other secondary causes is warranted for patients with orgasmic headache symptoms and for all patients with new-onset pre-orgasmic headache symptoms. (See 'Evaluation for other secondary causes for all patients' below.)
Evaluation for subarachnoid hemorrhage for patients with orgasmic headache symptoms — Urgent diagnostic evaluation is required for patients presenting with sudden-onset, orgasmic-type headache symptoms, to exclude SAH or other secondary causes (algorithm 1). Orgasmic headache is particularly worrisome because of its similarity to the headache of SAH, and because 4 to 12 percent of patients presenting with SAH due to an aneurysmal rupture cite sexual intercourse as the precipitating event [18,19].
The workup to exclude SAH typically includes:
●Head computed tomography (CT) to identify acute bleeding
●Lumbar puncture (LP) to identify xanthochromia in cerebrospinal fluid (CSF)
Additional testing may be warranted if initial testing is nondiagnostic (eg, blood in CSF attributed to traumatic LP) or delayed (eg, >2 weeks from symptom onset). Testing may also include digital subtraction angiography and brain magnetic resonance imaging (MRI) with gadolinium. The diagnosis of SAH is discussed in greater detail separately. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis", section on 'Evaluation and diagnosis'.)
After SAH has been excluded, if initial testing has not identified an alternative structural cause to symptoms, further testing to exclude other structural causes is warranted. (See 'Evaluation for other secondary causes for all patients' below.)
Evaluation for other secondary causes for all patients — For patients with orgasmic headache symptoms not attributed to SAH and for patients presenting with new-onset pre-orgasmic, dull headache symptoms, we suggest evaluation to exclude secondary causes.
Patients who present pre-orgasmic headache symptoms, a chronic history of multiple similar prior episodes consistent with primary headache associated with sexual activity, and a normal examination may not require additional diagnostic evaluation.
Secondary causes of sexual headache include reversible cerebral vasoconstriction syndrome, intracerebral hemorrhage, reversible posterior leukoencephalopathy syndrome, cervical artery dissection, cerebral venous thrombosis, and cardiac ischemia. Testing to exclude these conditions typically includes:
●CT- or MR-angiogram of head and neck
●MRI brain and MR venogram with gadolinium contrast
●Blood and urine toxicology screen
●Electrocardiogram
Additional testing for uncommon causes of thunderclap headache is typically reserved for patients with atypical symptoms or suggestive findings on initial evaluation. (See 'Differential diagnosis' below.)
A benign (ie, primary) sexual headache syndrome is likely if no abnormality is identified despite a thorough evaluation for structural, vascular, or pharmacologic causes.
DIFFERENTIAL DIAGNOSIS — Headaches occurring with sexual activity may represent a benign primary disorder. However, they may also be a symptom of an underlying and potentially malignant process. The differential diagnosis for sexual headache includes the following [8,9,20]:
●Subarachnoid hemorrhage – Subarachnoid hemorrhage (SAH) presents with a sudden, severe (thunderclap) headache in more than one-half of cases, and onset may occur during sexual activity [19]. However, SAH may also be associated with neck stiffness, loss of consciousness, and other nonfocal neurologic symptoms and is in general more protracted [2,21]. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis", section on 'Clinical presentation'.)
●Reversible cerebral vasoconstriction syndrome – Patients with reversible cerebral vasoconstriction syndrome (RCVS) typically present with sudden, severe (thunderclap) headache often associated with various physical triggers including sexual activity [22]. RCVS may be suspected when multiple thunderclap headaches occur during a single acute episode [17]. Characteristic findings on neuroimaging include multiple areas of segmental narrowing. In severe cases, brain imaging may show hemorrhage or ischemic stroke. (See "Reversible cerebral vasoconstriction syndrome", section on 'Clinical presentation and course'.)
●Intracerebral hemorrhage – Intracerebral hemorrhage (ICH) may occur spontaneously or with exertional activity, including sexual activity [23]. ICH is typically associated with sudden-onset neurologic symptoms related to the brain structures impacted. Some patients have headache, nausea or vomiting, and/or impairment of consciousness if the ICH is large. (See "Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis", section on 'Clinical presentation'.)
●Reversible posterior leukoencephalopathy syndrome – Reversible posterior leukoencephalopathy syndrome (RPLS; also called posterior reversible encephalopathy syndrome) is a syndrome consisting of acute or subacute headaches and impairment of consciousness associated with neuroimaging findings of subcortical edema. RPLS has been associated with hypertension, medications, and other sources that can lead to cerebral autoregulatory failure. (See "Reversible posterior leukoencephalopathy syndrome".)
●Ischemic stroke – Acute ischemic stroke is characterized by sudden onset of focal neurologic dysfunction. Headache is an uncommon feature of acute ischemic stroke. The diagnosis is made by brain and vascular neuroimaging. (See "Clinical diagnosis of stroke subtypes".)
●Cerebral and cervical (carotid or vertebral) arterial dissection – Headache is the most frequent initial symptom associated with dissection of an extracranial carotid or vertebral artery, and onset may be sudden [24]. The pain with dissection is typically ipsilateral, moderate to severe, and continuous. Arterial dissection may also cause a Horner syndrome or ischemic stroke symptoms. (See "Cerebral and cervical artery dissection: Clinical features and diagnosis", section on 'Clinical manifestations'.)
●Cerebral venous thrombosis – Headache is the most common symptom of cerebral venous thrombosis (CVT). Thunderclap or gradual onset may occur [25]. The pattern and severity of the head pain may vary but is typically continual, severe, and may worsen with Valsalva maneuvers. Some patients with CVT present with isolated headache, while others also have focal neurologic deficits or encephalopathy. (See "Cerebral venous thrombosis: Etiology, clinical features, and diagnosis", section on 'Clinical aspects'.)
●Spontaneous intracranial hypotension – Headache attributed to spontaneous intracranial hypotension is a positional type of headache that is typically relieved with recumbency and exacerbated with upright posture. The diagnosis should be considered in patients who present with positional orthostatic headache after sexual activity [17]. (See "Spontaneous intracranial hypotension: Pathophysiology, clinical features, and diagnosis", section on 'Causes of CSF leak'.)
●Meningitis and encephalitis – Most patients with meningitis and some with encephalitis present with severe headache. Onset may be acute in fulminant cases, such as with bacterial meningitis. Other common features in meningitis include fever, nuchal rigidity, and encephalopathy. Encephalitis most commonly presents with encephalopathy often with focal neurologic deficits. Lumbar puncture for cerebrospinal fluid analysis and neuroimaging can identify these diagnostic entities. (See "Clinical features and diagnosis of acute bacterial meningitis in adults", section on 'Clinical features' and "Viral encephalitis in adults", section on 'Clinical manifestations'.)
●Pheochromocytoma – Headache is a common clinical feature of pheochromocytoma but is typically associated with hypertension and autonomic symptoms. Evaluation for pheochromocytoma is warranted when symptoms such as prominent flushing, tachycardia, and sweating are present, particularly if these symptoms are present remote from sexual activity. (See "Clinical presentation and diagnosis of pheochromocytoma".)
●Cardiac ischemia – Because myocardial ischemia may occur during sexual intercourse [26], referred anginal pain should be considered as a potential cause of sexual headache in individuals with coronary risk factors. (See "Diagnosis of acute myocardial infarction", section on 'Clinical manifestations'.)
In addition, several other disorders have been suggested as possible causes for sexual headache in case reports. These include sinusitis, glaucoma, hypoglycemia, myxedema, anemia, chronic obstructive pulmonary disease, Cushing disease, and occlusion of the abdominal aorta [27,28].
TREATMENT — Treatment of primary headache associated with sexual activity includes symptomatic treatment of acute symptoms and preventive treatment to reduce the frequency and intensity of future attacks (algorithm 2). Treatment options are used after secondary causes have been excluded, as some medications are contraindicated in patients with a secondary cause to the headache. (See 'Our approach' above and 'Differential diagnosis' above.)
Acute symptomatic treatment — We suggest triptans for the initial acute treatment of most symptomatic patients diagnosed with primary headache associated with sexual activity. Our preference is intranasal or subcutaneous administration for acute therapy, based upon clinical experience, rapid onset of effect, and ease of use. Options include:
●Zolmitriptan 5 mg intranasal spray
●Sumatriptan 3 mg, 4 mg, or 6 mg subcutaneous injection
In a small case series of patients with orgasmic headache, acute triptan treatment was beneficial in about one-half [29].
For symptomatic patients unable to take a triptan due to intolerance or contraindication and for those whose symptoms do not resolve with initial triptan therapy, we try an alternative medication. We use a nonsteroidal anti-inflammatory medication or an antiemetic agent, based largely on efficacy for the acute treatment of other primary headache disorders. Options include:
●Naproxen 500 mg per os (PO; orally)
●Ketorolac 30 mg intravenous (IV) or 60 mg intramuscular (IM)
●Metoclopramide 10 mg IV
●Prochlorperazine 10 mg IV or IM
Antiemetic options may be preferred for older adults and those with an elevated risk of adverse effects with nonsteroidal anti-inflammatory medications due to cardiovascular, gastrointestinal, or kidney disease. (See "Nonselective NSAIDs: Overview of adverse effects".)
Preventive treatment — For most patients with recurrent symptoms (2 or more episodes) of headache associated with sexual activity, we suggest indomethacin or propranolol for initial preventive treatment. For patients who are intolerant or unresponsive to indomethacin or propranolol, we use sumatriptan. For most patients, we prefer anticipatory pretreatment over daily therapy to minimize the risk of medication adverse effects with long-term prophylaxis. Daily therapy may be preferred by some patients with frequent attacks who are unable to adhere to an anticipatory regimen.
●Anticipatory pretreatment options – We suggest anticipatory pretreatment be taken typically 30 to 60 minutes before sexual activity. Dosing and initial options include:
•Indomethacin 25 mg orally, titrated to effect up to 150 mg
•Propranolol 40 mg orally, titrated to effect up to 200 mg
•Sumatriptan 6 mg subcutaneous injection
We start with either indomethacin or propranolol for most patients due to tolerability and experience with efficacy [30]. Propranolol may be preferred for patients with an elevated risk of adverse effects with indomethacin due to cardiovascular, gastrointestinal, or kidney disease. Indomethacin may be preferred for those with an elevated risk of adverse effects with propranolol, such as patients with bradycardia, hypotension, cardiac conduction abnormalities, or reactive airway disease. (See "Nonselective NSAIDs: Overview of adverse effects" and "Major side effects of beta blockers".)
For patients refractory to or intolerant of indomethacin and propranolol, we use a triptan [29,31]. The choice among the available triptans should be individualized; different pharmacologic properties and delivery routes may help guide the selection. Sumatriptan can be given as a subcutaneous injection, as a nasal spray, or orally. Zolmitriptan is also available for both nasal and oral use. The others are available for oral use only. Based upon clinical experience and onset of effect, we prefer subcutaneous sumatriptan be given 30 to 60 minutes before sexual activity. For intercourse that will begin in two to four hours, oral formulations of triptans, including sumatriptan, zolmitriptan, almotriptan, rizatriptan, or eletriptan, may be used. For intercourse that will begin in more than four hours, oral frovatriptan or naratriptan are preferred because of their long half-life.
●Daily medications – For patients who take daily preventive therapy, we typically start at a low initial dose, increasing gradually to effect and tolerance. Dosing and initial options include:
•Indomethacin 25 mg orally once daily, up to maximum dose of 225 mg orally once daily
•Propranolol 40 mg orally once daily, up to maximum dose of 240 mg orally once daily
In case series, indomethacin and propranolol were reported to be effective in up to 80 to 90 percent of patients [27,29,30,32,33]. Some benefit has also been reported with other beta-blockers, triptans, topiramate, and calcitonin gene-related peptide receptor antagonists [27,30,33-35].
Preventive medications may be discontinued by stepwise dose tapering, typically 6 to 12 months after symptoms have resolved. The rate of spontaneous remission is high for primary headache associated with sexual activity. (See 'Prognosis' below.)
In one case series, the advice to engage in sexual intercourse more frequently but less strenuously resulted in an apparent reduction in headaches [33].
PROGNOSIS — The prognosis for primary sexual headache is generally quite good, even for those cases associated with transient neurologic symptoms [1,9,30]. In one case series that included 60 patients who were followed for an average of 36 months, symptoms occurred only once in 75 percent [30]. Among patients with a chronic course of sexual headache at baseline, the remission rate at three years was 69 percent.
Persistent neurologic deficits following sexual headaches have been reported rarely [36]; any persistent deficit requires investigation to evaluate for stroke or other underlying cause.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Migraine and other primary headache disorders".)
SUMMARY AND RECOMMENDATIONS
●Epidemiology – Primary headache associated with sexual activity is a rare type of headache with a lifetime prevalence of approximately 1 percent. The mean age of onset is 37 to 39 years of age and the male to female ratio is 3:1. (See 'Epidemiology' above.)
●Clinical features – Headache associated with sexual activity is bilateral in approximately two-thirds of patients and unilateral in one-third. In most patients, the localization is occipital or diffuse. Traditionally, two types are described (see 'Clinical features' above):
•Pre-orgasmic headache – This "dull type" typically features pressure-like or aching pain that appears during sexual activity and gradually increases with mounting sexual excitement. Symptoms typically persist for about 30 minutes on average with a range from 1 to 180 minutes.
•Orgasmic headache – This headache may be called the "explosive type," characterized by a sudden onset of severe head pain that occurs just prior to or at the moment of orgasm and followed by severe throbbing head pain. The severe pain often lasts for <15 minutes, but the subsequent throbbing head pain often persists for several hours. Orgasmic headache accounts for up to 70 percent of primary headache associated with sexual activity.
Despite differences in clinical description of the two subtypes, primary headache associated with sexual activity appear to be a single entity with variable presentations.
●Diagnosis – The diagnosis of primary headache associated with sexual activity is made in patients with characteristic headache symptoms occurring during sexual activity after secondary causes have been excluded. (See 'Evaluation and diagnosis' above.)
●Evaluation – All patients reporting sudden-onset, severe symptoms, including those with orgasmic onset of symptoms, should be evaluated urgently for subarachnoid hemorrhage (SAH) and other acute conditions that may present with sudden-onset headache (algorithm 1).
Further evaluation for other secondary causes is warranted once SAH has been excluded. Patients who present with the new-onset pre-orgasmic headache symptoms should be evaluated for secondary causes with neuroimaging. (See 'Evaluation and diagnosis' above.)
●Differential diagnosis – Several secondary headache conditions may occur with sexual activity, including SAH, reversible cerebral vasoconstriction syndrome, and arterial dissection. (See 'Differential diagnosis' above.)
●Treatment – Treatment of primary headache associated with sexual activity includes symptomatic treatment of acute symptoms and preventive treatment to reduce the frequency and intensity of future attacks (algorithm 2). Treatment options are used after secondary causes have been excluded, as some medications are contraindicated in patients with a secondary cause to the headache. (See 'Treatment' above.)
•Acute symptomatic treatment – We suggest triptans for the acute symptomatic treatment of symptomatic patients with primary headache associated with sexual activity (Grade 2C). Preferred agents are zolmitriptan intranasal spray 5 mg or sumatriptan 6 mg by subcutaneous injection. Alternative options include nonsteroidal anti-inflammatory medications and antiemetics. (See 'Acute symptomatic treatment' above.)
•Preventive treatment – For most patients, we suggest anticipatory pretreatment with either indomethacin or propranolol for initial preventive therapy of primary headache associated with sexual activity (Grade 2C). For patients who are intolerant or unresponsive to indomethacin or propranolol, we use sumatriptan. (See 'Preventive treatment' above.)
