The Clinical Syndrome
Sexual headache, which is also known as primary headache associated with sexual activity, is a term used to describe a group of headaches associated with sexual activity. Clinicians have identified the following three general types of headache associated with sexual activity:
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Explosive type
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Dull type
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Postural type
Each of these sexual headache types was previously called benign coital headache, but this term has been replaced by sexual headache because each may occur with sexual activity other than coitus ( Fig. 6.1 ). 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. There is no gender predilection for 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.
Signs and Symptoms
Patients with sexual headache present differently depending on the type of sexual headache experienced. Each clinical presentation is discussed subsequently.
Explosive Type of Sexual Headache
The explosive type of sexual headache is the most common type of sexual headache encountered in clinical practice. The patient usually fears he or she has had a stroke. The patient may be less forthcoming about the circumstances surrounding the onset of headache, and tactful questioning may be required to ascertain the actual clinical history. The explosive type of sexual headache occurs suddenly, with an almost instantaneous onset to peak just before or during orgasm. The intensity of the explosive type of sexual headache is severe and has been likened to the pain of acute subarachnoid hemorrhage. The location of pain is usually occipital, but some patients volunteer that the pain felt “like the top of my head was going to blow off.” The pain is usually bilateral, but isolated cases of unilateral explosive sexual headache have been reported. The pain usually remains intense for 10 to 15 minutes and then gradually abates. Some patients note some residual headache pain for 2 days.
Dull Type of Sexual Headache
The dull type of sexual headache begins during the early portion of sexual activity. This headache type has an aching character and begins in the occipital region. The headache becomes holocranial as sexual activity progresses toward orgasm. It may peak at orgasm, but in contrast to the explosive type of sexual headache, the dull type disappears rapidly after orgasm. Ceasing sexual activity usually aborts the dull type of sexual headache. Some headache specialists think the dull type of sexual headache is simply a milder version of the explosive type of sexual headache.
Postural Type of Sexual Headache
The postural type of sexual headache is similar to the explosive type of sexual headache in that it occurs just before or during orgasm. Its rapid onset to peak and severe intensity also are similar to that of the explosive type. It differs from the explosive type of headache in that the headache symptoms recur when the patient stands up, in a manner analogous to postdural puncture headache. The postural component of this type of sexual headache is thought to be due to minute tears in the dura that may occur during intense sexual activity.
Testing
Magnetic resonance imaging (MRI) of the brain provides the best information regarding the cranial vault and its contents. MRI is highly accurate and helps identify abnormalities that may put the patient at risk for neurological disasters secondary to intracranial and brainstem pathological conditions, including tumors, demyelinating disease, and hemorrhage. More importantly, MRI helps identify bleeding associated with leaking intracranial aneurysms. Magnetic resonance angiography (MRA) and cerebral arteriography may be useful in helping identify aneurysms or other arterial abnormalities responsible for the patient’s neurological symptoms ( Figs 6.2 and 6.3 ). In patients who cannot undergo MRI, such as patients with pacemakers, computed tomography (CT) is a reasonable second choice. Even if blood is not present on MRI or CT, if intracranial hemorrhage is suspected, lumbar puncture should be performed.
