Margaret J Redelman
Headaches and sexual activity are often treated with humour as a typical way for women to reject male advances. However, headaches associated with sexual activity can be anything but a joke.
HSA (headaches associated with sexual activity) are by definition benign conditions but the symptoms can be the same as in serious life threatening cerebral conditions and these need to be quickly excluded at the first presentation. Most sexual headaches are of a benign nature. However, the first time an HSA occurs it can be a traumatic, frightening occurrence for the patient. HSA are capricious in nature with poorly understood pathophysiology and uncertain course of the condition. Patients need to have the situation clearly explained to them so that management can be optimal.
However, good overall management of a patient with HSA should also include discussions about possible negative sexual consequences of the HSA experience. Sexuality can be affected by HSA both during the active condition and subsequently. Sexuality must be addressed by the treating physician if the patient/couple are not to be left with an ongoing negative effect on their future sex life as a consequence of the HSA.
Keywords: sexual headache, sex, sexuality, headache
Headaches associated with or occurring around sexual activity have been recognized since the time of Hippocrates [1, 2]. Wolff  discussed headache during sexual activity in 1963. However, these headaches started to be formally reported in the 1970s, first by Kitz in 1970  and then Paulson  and Martin  in 1974. The first published study was by Lance in 1976 .
This type of headache has been given many different names: benign sex headache (BSH), benign coital headache, coital cephalgia, orgasmic cephalgia, primary headache associated with sexual activity (PHSA), coital ‘thunderclap’ headache, primary thunderclap headache (PTH), orgasmic headache (OH) and preorgasmic headache.
In 2004the International Headache Society  classified HSA as a distinct form of primary headache.
These benign HSA are bilateral headaches, precipitated by sexual excitement (masturbation or coitus) occurring in the absence of any intracranial disorder and which can be prevented or eased by ceasing activity before orgasm. Type 1 consists of a bilateral, usually occipital, pressure-like headache that gradually increases with mounting sexual excitement. Type 2 headaches have an explosive, throbbing quality and appear just before or at the moment of orgasm. These often start occipitally but may generalize rapidly .
However, there are individuals who experience patterns of HSA that do not fall within the classifications and are included as a subgroup of HSA with unusual psychopathology . For example, Paulson and Klawans  described a rare type postural sexual headache after coitus, which is present on standing, eased by lying, accompanied by a low CSF pressure, and persists for several weeks.
International Headache Society diagnostic criteria - ICHD-2(7) classification for HSA
4.4 Primary headache associated with sexual activity
4.4.1 Pre-orgasmic headache
A. Dull ache in the head and neck associated with awareness of neck and/or jaw muscle contraction
and fulfilling criterion B.
B. Occurs during sexual activity and increases with sexual excitement
C. Not attributed to another disorder
4.4.2 Orgasmic headache
A. Sudden severe (“explosive”) headache fulfilling criteria B
B. Occurs at orgasm
C. Not attributed to another disorder
7 Secondary headache disorder
7.2.3 Headache attributed to spontaneous (or idiopathic) low CSF pressure
HSA are not common but it is generally felt that they are under-reported due to patient embarrassment  at telling health professionals when their headaches occur. Prevalence in the general population is reported at around 1% [11, 12] and is greater in men than in women, by 3-4 times [11, 13-16]. There appear to be two peak times of onset: in the early 20s and then around age 40 . About 22% of HSA are Type 1 and 78% are Type 2 . The male:female ratio is the same for Type 1 and Type 2 headache.
HSA are not clearly understood but by definition lack serious underlying disease. They are however, unpleasant, frightening, repetitive and episodic. The clinical characteristics of Type 1 suggest a relationship with tension/muscular contraction headaches [2, 13, 15, 16]. There is a significant association between the risk of having more than one cluster of HSA and the presence of tension headaches or migraine [11, 14-17, 19-21]. Biehl  concluded that the association between migraine and HSA is bilateral. The prevalence of migraine in HSA patients is 25-47% [15, 16, 20]. Ostergaard  showed that the presence of concomitant migraine or tension headache was significantly associated with the recurrence of periods lasting weeks to months in which HSA occurred. Patients without another primary headache often have only one HSA period or episode and a more favourable prognosis . Migraine is co-morbid in 30% of Type 2 as opposed to 9% with Type 1. Co-morbidity is also seen in exertional headaches, 35% of Type 2 and 9% Type 1[17, 18]. There can be simultaneous onset of benign exertional headache (BEH) and HSA  as well as HSA after a history of BEH [16, 22].
Several drugs have been linked in case reports to sexual headaches associated with neurologic symptoms: Amiodarone , birth control pills , pseudoephedrine  and cannabis .An interesting more recent addition to HSA is that resulting from the use of PDE5 medication to assist in erectile difficulties [26, 27].
In type 2 headaches, increased intracranial pressure secondary to a Valsalva maneuver during orgasm has been proposed as a possible mechanism. Blood pressure may increase by 40-100mmHg systolic and 20-50mmHg diastolic during orgasm [7, 28-30]. A possible disruption of autoregulation of the cerebral vasculature has also been proposed [31-33].
A male patient, middle-aged, in poor physical shape, mildly to moderately overweight, and mildly to moderately hypertensive . In women muscle contraction and psychological factors are often involved .
The typical story is that the headache occurs during sexual activity, is bilateral and stops or is less severe if sexual activity stops prior to orgasm. The duration varies from 5 minutes to 2 hours if sexual activity stops and from 3 minutes to 4 hours, with the possibility of milder symptoms up to 48hours, if activity continues.
With the first episode it is absolutely mandatory to exclude potentially life threatening and disabling causes. A thorough history and neurological examination with the option of imaging studies and CSF examination must be conducted.
Type 2 explosive “thunderclap” headaches can be secondary to subarachnoid haemorrhage, aneurysms without obvious rupture, intracerebral haemorrhage, pituitary apoplexy, venous sinus thrombosis, cervical artery dissection, subdural haematoma, haemorrhage into an intracranial neoplasm , cerebral tumour , intracranial hypotension and hypertension, significant cervical spine disease, and ischaemic stroke [37-43] and these serious conditions need to be excluded before an HSA diagnosis can be given. HSA may present similarly to paroxysmal headaches caused by phaeochromocytoma .
Sexual intercourse is reported as a precipitating cause of subarachnoid haemorrhage in 3.8% to 12% of patients with bleeding from a ruptured aneurysm .
Course of the disease
The unpredictable clinical course falls into 2 temporal patterns: an episodic course with remitting bouts, and a chronic course . In most cases the headaches occur in bouts that recur over periods of weeks to months before resolving [16, 45].
The episodic type is defined as a bout of at least 2 attacks occurring in ≥ 50% of sexual activity followed by no attack for ≥ 4 weeks despite continuing sexual activity. The chronic course is defined as ongoing HSA attacks for ≥ 12 months without remission of ≥ 4 weeks .
Further uncertainty is experienced by the patient as HSA does not necessarily occur in every sexual encounter [7, 19]. A characteristic of HSA is the sporadic vulnerability of patients to the headache. Episodes can occur singly, in clusters or at irregular intervals. Recurrence can occur years later.
The acute HSA attacks are usually short lasting but the overall duration of pain can vary widely . The mean duration of severe pain in HSA is similar (30 minutes) in type 1 and type 2 but the mean duration of milder pain is more prolonged with type 2 (4 hours vs 1 hour). About 15% of patients suffer from severe pain for >4hours needing acute treatment. Severe pain continuing for 2-24 hours occurs in up to 25% of patients with HSA . Patients with episodic HSA compared to chronic HSA have an earlier age at onset and tend to suffer more often from concomitant BEH .
About 30% of patients report headaches with masturbation as well as intercourse. There are also reports of HSA occurring exclusively during masturbation [46, 47] and a case of this occurring with nocturnal emission .
Overall HSA occurs more commonly when the patient is tired, under stress or attempting intercourse for the second or third time in close succession . HSA appears in bouts lasting weeks to months and can disappear without specific treatment [14, 16]. The number of attacks within one bout ranges from 2 to 50 . About 25% of patients suffer attacks without longer remissions.
Prognosis is usually good for HSA as it is a benign self- limiting disorder and disappears without any specific treatment in the majority of patients . It is usually better if there has been only one attack, especially if it was not associated with any other type of headache.
Frese  concluded that episodic HSA occurs in approximately 75% and chronic HSA in approximately 25% of patients. However even in chronic HSA, the prognosis is favourable, with remission rates of 69% in patients followed over 3 years.
A thorough history and examination is mandatory in a first attack.
Referral is warranted if:
Atypical story and suspicious examination
First episode of severe headache where headache still present
A recurrent episode of severe headache with longer than average duration
Neck stiffness, photophobia or vomiting
Altered consciousness or confusion
Focal neurological signs
Previous history of AV malformation, neoplasms or neurosurgery
Turner  has provided a good review.
Propanolol hydrochloride ( Inderal) is effective in the prophylaxis of HSA. Naratriptan 2.5mg has been reported as useful prior to sexual activity  but due to lower absorption rates needs to be taken more than 60 minutes before sexual activity . Indomethacin 25-100mg can be taken 30-60 minutes prior to sexual activity [15, 16, 45, 51] and for acute severe pain management  but can cause serious gastrointestinal side-effects and is not tolerated by about 10% of headache patients .
Triptans shorten the attack in about 50% of patients. There is an 80% response rate . Analgesics (ibuprofen, diclofenac, paracetamol, acetylsalicylic acid) given after onset of headache are of limited or no value in nearly all patients .
Other triptans, ergots and benzodiazepines have also been reported to have efficacy [5, 24, 53, 54] for acute and pre-emptive treatment for those patients not tolerating indomethacin. Taken 30 minutes before sexual activity they shorten orgasmic headache attacks in 66% of users .
Long term prophylaxis for longer lasting bouts or continued attacks
Options include indomethacin 25mg three times a day, propanolol 120-240mg per day, metoprolol 100-200 mg per day and diltiazem 180 mg per day [15, 19, 20, 22, 24, 45]. There is about an 80% response rate .
Trauma due to pain associated with sexual activity has the potential to affect immediate and long term satisfaction with sexual activity unless specifically addressed. HSA can be very distressing for both patient and partner with the development of fears around sexual activity and orgasm. Patients may develop patterns of impaired sexual arousal. If these fears are not exposed and dealt with, sexual problems may occur. Secondary avoidance behaviours may become established in the relationship leading to a decrease in couple’s physical affection, eroticism and sexual activity. Patients must be given the opportunity to talk about sexual fears in an ongoing way, especially if HSA is chronic.
The social and relationship history will disclose areas of stress which should be evaluated and managed as best possible. In type 1 HSA where neck and jaw tension may be a factor, conscious relaxation of these muscles during intercourse may help . Relaxation exercises especially concentrating on neck and shoulder tension can be done regularly and particularly before anticipating sexual activity.
Individuals often sense early in the lovemaking process whether or not HSA will occur and encouragement not to pursue orgasm on that occasion can be helpful. Some patients can terminate the headache by stopping the sexual activity or suppressing orgasm and about 51% can lessen the intensity of pain by being more sexually passive .
Advice on continuing to engage with the partner despite ceasing or modifying one’s own sexual arousal needs to be given. Having a disappointed or resentful partner increases the distress of the condition so partner needs have to be discussed. Patients often have difficulty talking about sexual issues with both their partner and their doctor, therefore the doctor needs to be the one to raise the subject.
A brief sexual history will outline the love-making practice and modification to sexual positions, especially where neck tension is exaggerated, may help. In one report, the advice to engage in intercourse more frequently but less strenuously resulted in a reduction in headaches .
Avoiding sexual activity and strenuous activities until totally symptom free has been recommended by some [13, 22, 24, 55]. This may be difficult to follow as the capricious nature of HSA makes knowing when they have stopped difficult.
HSA are benign, but because they can mimic serious conditions, patients need to be properly assessed before reassurance is given and management of HSA started. Because pain can alter sexual experience and behaviour around sexuality for the patient and the couple, this aspect of patient wellbeing must be addressed by the treating physician for good holistic management. As not everyone is comfortable with addressing sexuality with patients, respectful acknowledgement of the situation and appropriate referral can be a useful approach.
MARGARET J REDELMAN, MBBS MPsychotherapy, Sydney Centre for Sexual and Relationship Therapy Consultant, 40 Grosvenor St, Bondi Junction NSW 2022, Australia.
CORRESSPONDENCE: MARGARET J REDELMAN, MBBS MPsychotherapy, Sydney Centre for Sexual and Relationship Therapy Consultant, 40 Grosvenor St, Bondi Junction NSW 2022, Australia.
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