Headache Associated With Sexual Activity

Description

The International Headache Society (1988) classifies headache associated with sexual activity (HSA) as an idiopathic headache under 'miscellaneous headaches unassociated with structural lesions.' Based on initial descriptions, 3 subtypes are differentiated: type 1 is a dull ache in the head and neck that slowly intensifies as sexual excitement increases, and is believed to be caused by muscle contraction similar to tension-type headache; type 2, also called 'vascular-type,' is a sudden severe, explosive headache occurring at orgasm, which may be due to increased intracranial pressure; type 3, the most uncommon type, is a postural headache resembling that caused by decreased CSF pressure, perhaps due to a meningeal tear during coitus (summary by Frese et al., 2003).

Clinical Features

Johns (1986) reported 4 sisters with the vascular type of benign sexual headache (type 2 HSA). The most severely affected patient was successfully treated with beta-blocker prophylaxis. In a review of the literature, the author found that 28% of those affected had either personal history or family history of migraine (see 157300), suggesting that type 2 HSA is a migraine variant.

Among 51 patients diagnosed with HSA, Frese et al. (2003) found that HSA type 2 was the most common, occurring in 40 patients. Eleven patients had HSA type 1, and no patient had HSA type 3. There was a clear male preponderance (2.9:1). For the whole group, the mean age at onset was 35.2 years, with a first peak between 20 and 24 years and a second peak between 35 and 44 years. Pain was predominantly, but not exclusively, occipital or diffuse, and the duration of pain varied widely from less than 15 minutes to 12 hours. Most patients had longer lasting, milder pain (approximately 4 hours). The usual setting for headache was sexual activity with the usual partner (94%), followed by masturbation (35%). Sixty-one percent of the patients had other headache disorders, including episodic tension-type (in 18), benign exertional (in 15), migraine (in 13), and chronic tension-type (in 5). The only significant difference between types 1 and 2 were time of onset: minutes before orgasm for type 1 and concurrent with orgasm for type 2. Arterial hypertension was not a risk factor.