Jeff Baker: A 24-Year-Old Medical Student With Severe Episodic Headache Associated With Sexual Activity

Learning Objectives

  • Learn the common types of headache.

  • Understand the difference between primary and secondary headaches.

  • Develop an understanding of clinical presentation of specific headache types.

  • Develop an understanding of the treatment of specific headache types.

  • Develop an understanding of the differential diagnosis of primary headaches.

  • Understand the gender predilection of specific headache types.

  • Learn how to identify factors that cause concern.

Jeff Baker

Jeff Baker is a 24-year-old medical student with the chief complaint of headache associated with sexual activity. Jeff shook hands with me and said, “Doctor, I have one for you. It’s kind of embarrassing to talk about, but my partner is really worried about me and wanted me to see if you could help.” I reassured Jeff that I would certainly try and that whatever it was he was in a judgment-free zone, so there was nothing to be embarrassed about. I also reassured him that anything we discussed would be held in the strictest confidence. He seemed to relax a bit, so I said, “Jeff, tell me what’s going on and together we will get it sorted out.”

“Well, whenever I have sex, when I start to really get excited, I start to get this dull pain in my occipital area and neck, and if I keep going it spreads and gets really intense—not the sex, the headache. The headache is not helping the sex at all; it’s a real party pooper, if you know what I mean.” “Do you mean inability to get an erection?” I asked, and he said, “Not so much that, but I am starting to be afraid to have sex. I don’t want to have a stroke or anything. Like I said, my partner is really worried about me, but is getting frustrated about the sex thing.” I nodded and said that I understood.

I asked Jeff if he had any symptoms associated with the headache and he shook his head. “Doctor, there is no aura, if that is what you are asking. No photophobia, sonophobia, or osmophobia like migraine. My diagnosis is this is not migraine.” I smiled and said that I was glad he didn’t sleep through his neurology lectures. He laughed and seemed more relaxed. I asked if the headache occurred with all sexual activity, masturbation, oral sex, or just with sexual intercourse and he said it happened with all types of sexual activity. “The more excited I get, the worse the headache gets.” I asked about any other constitutional symptoms or neurologic symptoms, and Jeff said no. He also denied the use of erectile dysfunction drugs or the use of illicit drugs during sexual activity, including cocaine and amyl nitrate poppers.

I asked Jeff what made his headache better, and he said, “Really nothing, other than avoiding sex. No sex, no headache. I’ve tried all the usual over-the-counter medications and they do absolutely nothing—not before I have sex or when the headache starts.”

I asked Jeff to use one finger to point at the spot where it hurt the most when the headache came on, and he pointed to the occipital region. “Both sides, Doc, and then down into the neck and up to the vertex of the scalp.” I asked Jeff what the pain was like and he said it started as an ache and increased in intensity as he got more sexually excited. I asked if it was associated with orgasm and he said no, it was at its worst just before orgasm and then gradually subsided after orgasm. “Like I said, this is not helping my sex life and I feel bad for my partner having to deal with this.”

I said, “Let’s look you over.”

I asked Jeff if I could examine him and he said, “Sure, but there is not much to see.” On physical examination, Jeff was afebrile. His respirations were 16 and his pulse was 70 and regular. His blood pressure was 118/70. There were no cranial abnormalities. His head, eyes, ears, nose, throat (HEENT) examination was completely normal, as was his fundoscopic examination. Temporal arteries were normal bilaterally. His neck examination was normal, and no myofascial trigger points were identified. His cardiopulmonary examination was normal, as was his thyroid. There was no adenopathy. His abdominal examination revealed no abnormal mass or organomegaly, and there was no rebound tenderness present. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. A careful neurologic examination of the upper and lower extremities revealed no evidence of weakness, lack of coordination, or peripheral or entrapment neuropathy, and his deep tendon reflexes were normal. The remainder of his neurologic examination was completely normal.

I reassured Jeff that I didn’t find anything on physical examination that was cause for concern. “So, Jeff, I have a pretty good idea what is going on and what to do about it, but I’m curious. What is your diagnosis?” Jeff said, “Either sexual headache or I’ve got a leaky aneurysm.” I said, “Jeff, I think we should go with the first one!”

Key Clinical Points—What’s Important and What’s Not

The History

  • Episodic headache associated with all sexual activity

  • Headache that worsens during sexual excitement, but orgasm does not affect intensity

  • No prodrome or aura

  • Severe headache pain

  • Bilateral headache

  • Headache that begins as a suboccipital ache but progresses during increasing sexual excitement to involve the neck

  • Headache not associated with neurologic signs or symptoms

  • Patient denies fever, chills, or other constitutional symptoms

  • Patient denies significant nausea and vomiting associated with headache

The Physical Examination

  • Patient is afebrile

  • Normal fundoscopic exam

  • Examination of the cranium is normal

  • Neurologic exam is normal

Other Findings Of Note

  • Normal cardiovascular examination

  • Normal pulmonary examination

  • Normal abdominal examination

  • No peripheral edema

What Tests Would You Like to Order?

The following test was ordered:

  • Magnetic resonance imaging (MRI) of the brain

Test Results

The MRI of the brain was normal.

Clinical Correlation—Putting It All Together

What is the diagnosis?

Sexual headache

The Science Behind the Diagnosis

Clinical Syndrome

Sexual headache is a term used to describe a group of headaches associated with sexual activity. Sexual headache is also known as primary headache associated with sexual activity, benign vascular sexual headache, coital cephalalgia, coital headache, intercourse headache, (pre)orgasmic cephalalgia, and (pre)orgasmic headache ( Fig. 5.1 ). Clinicians have identified the following three general types of headache associated with sexual activity: (1) explosive type, (2) dull type, and (3) postural type, with each type having a preorgasmic and an orgasmic variant. In general, sexual headache includes a benign group of disorders, but a rare patient may have acute subarachnoid hemorrhage during sexual activity, which may be erroneously diagnosed as the benign explosive type of sexual headache ( Fig. 5.2 ). There is a slight gender predilection for males suffering sexual headache, and the occurrence of all types of sexual headache may be episodic rather than chronic. Rarely, more than one type of sexual headache occurs in the same patient. Sexual headaches have been associated with the use of cannabis, pseudoephedrine, oral contraceptives, and amiodarone.

Apr 16, 2022 | Posted by in PAIN MEDICINE | Comments Off on Jeff Baker: A 24-Year-Old Medical Student With Severe Episodic Headache Associated With Sexual Activity
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