Case Studies in Headache: Headaches with Sexual Activity

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By Katherine Margo, M.D.
Director of Student Programs, University of Pennsylvania School of Medicine, Department of Family Medicine and Community Health, Philadelphia, Pennsylvania

THE CASE
Mario is a 40-year-old man who has had migraines off and on since he was a teenager. He is able to keep them under control with occasional use of headache-specific medication or ibuprofen. He is in a new relationship, however, and has started having severe headaches all over his head as soon as he achieves a climax during sexual intercourse. This has happened several times and it’s quite distressing. He is worried that it might be something “really serious.” It is also interfering with his relationship in that his partner is reluctant to have intercourse for fear of triggering an attack.

DISCUSSION
One particularly unfortunate trigger for headache is orgasm. No one really knows how common this type of headache is because people are often too embarrassed to talk about it. We do know that headaches that occur with sexual activity are more common in men than in women. They also tend to occur in people with a history of other types of migraines.

There are three basic types of sexual headaches:

  • A dull ache in the head, neck and jaw that intensifies with sexual excitement
  • A sudden and severe headache that occurs with orgasm
  • A headache that occurs with sitting up after intercourse

The second type—headache with orgasm—is the most common and what Mario was experiencing. These headaches usually start just before or with orgasm, are very intense and can be quite alarming. They are usually felt on both sides of the head or in the back of the head and tend to be of short duration (up to about 30 minutes, though a duller headache can last up to four hours). While they can last longer than three hours, it’s usually due to an underlying cause. These headaches can occur only once or in clusters over weeks to months, but most people who have them once have them again.

Like migraines, they can be associated with nausea, vomiting and sensitivity to light. They are also similar to exertional headaches, which happen with coughing or exercise. In fact, about 40% of people with sexual headaches have a form of exertional headache as well.

At this point, we don’t know what causes most of these headaches. Rarely, they are caused by a brain hemorrhage, so a medical evaluation should be done after the first occurrence to ensure that there is no serious cause. Once it has been determined that there is no underlying problem, reassurance goes a long way to helping these patients cope.

Unfortunately, there is no one clear medical treatment for most sexual headaches so patients need to experiment to find what works best for them. Some people get relief from indomethacin or similar medications taken 30 to 60 minutes before intercourse. Anti-migraine medications can sometimes help as well. Preventive treatments such as amitriptyline and propranolol, and blood pressure medications like verapamil can be very useful. Taking a nonsteroidal anti-inflammatory medication like ibuprofen before intercourse does not seem to help much, but ergotamine-containing medications taken that way have been shown to help with the headache pain. Triptans, particularly the shorter acting forms (rizatriptan or eletriptan) may be useful as well, though studies have not been done to determine their effectiveness for sexual headaches.

CASE CONCLUSION
The good news is that sexual headaches are generally self-limited or controllable with the medications described above. Mario tried taking indomethacin 30 minutes before sexual activity and found, to his relief, that he had many fewer headaches and the headaches he did have were minor.

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