Discussion
Primary headache associated with sexual activity is seen approximately
in 0.9-1.6% of the population (3,5). It may be developed at any
sexually active age, seen in both genders but commonly in 3rd and
4th decades, hypertensive or obese males in a ratio
range between 1,2:1 – 3:1(1,2,6). In our patient group followed at
headache outpatient clinic, 2% of the patients had primary headache
with sexual activity. The mean age was 37.07± 7.67 and there was a male
predominance relevant to the literature.
Even though the pathophysiology is not known exactly, one of the
theories is to be a mechanism of trigeminovascular effect with the
addition of muscular component and impaired cerebrovascular
autoregulation (1,7). Some authors suggested an excessive release of
neurotransmitters or catecholamines (8,9). Donnet et al have
investigated the patients with craniocervical venography and detected
venous stenosis in 12/19 of the patients suggesting this to promote the
headache during the sexual activity (10).
Albeit it is classified as primary, at first onset it can be a symptom
of subarachnoid hemorrhage, cerebral venous thrombosis, stroke, carotid
artery dissection or reversible cerebral vasoconstriction syndrome
therefore intracranial pathologies should be reminded on differential
diagnosis so neurological (MR imaging ), neurovascular imaging
(MR angiography, MR venography ) and transcranial doppler
ultrasonography must be performed (11,12).
Initially it was used to be classified as three different types
previously and 80% of the patients had been reported as orgasmic
headache (6,13). In our patient group only 38.5% of the patients had
headache during orgasm. But on ICHD-3 these terms have been united as
the pathophysiology has not been differentiated yet. The pain is
characterized as dull and usually bilateral, must take at least two
episodes, usually at occipital area, neck region or diffuse with the
duration that lasts from minutes to hours as sexual activity increases
and it becomes most powerful at orgasm. The headache appears
individually from the type of sexual activity. In some researches it is
believed that it can course up to one year (1,2,7).
Extramarital sexual affairs may be a risk factor for HAS. Stress or
fatigue may precipitate recurrent headache (14). In the literature 2
patients were reported with vertigo as an aura without headache during
orgasm (11). The autonomic or vegetative symptoms do not usually
accompany headache but a few patients may have nausea, phonophobia,
photofobia or dizziness (6,10). None of our patients had either aura or
accompanying symptoms.
In preceding researches, it was suggested that there was a possible link
between other primary headache disorders as migraine (19-30%), tension
type headache (27%), cluster headache (2%) and exertional headache
(29-40%) with HAS (1,3,6,10,15-17). As both HAS and a primary
exertional headache present a sudden initiation during an activity, it
was suggested that in some of the patients with primary headache with
sexual activity might be an analogue of exertion associated with orgasm
(15). Primary sexual headache disorder was suggested to share the
similar vascular hyperreactivity with migraine (18). Both migraine and
HAS may have a genetic basis and both respond to prophylactic beta
blockage therapy and acute treatment with naratiptan (19,20). Both of
the headache may present with vegetative symptoms and HAS may also be
unilateral (20). Five of our patients had a preceding migraine history
as suggested.
As concerns the treatment, prevention with indomethacin 30 minutes
before sexual activity is sufficient in many cases but for the patients
that suffer for a long-term period, the prophylaxis
could be made with indomethacin with the dosage between 25-50mg/day or
propranolol 40-200mg/day for 3 to 6 months (1,3,20).Ergotamine
1-2mg/day, diltiazem 180mg/day, topiramate 50mg/day and greater
occipital nerve blockage are alternative options for the patients that
can not tolerate drugs (7,21-23). We have successfully treated 10 of
patients with indomethacin before sexual activity and 3 patients were
treated with propranolol prophylaxis.
In conclusion, even though primary headache associated with sexual
activity is an infrequent syndrome, the awareness should be raised upon
specialists and be reminded on differential diagnosis. Once the
diagnosis is certain, it is important to provide the appropriate
treatment, reassure the patient about its benign nature and
self-limiting progress.