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.