From the Guidelines
Coital cephalagia, also known as sex headache or orgasmic headache, is a sudden, severe headache that occurs during sexual activity, particularly around the time of orgasm, and patients should seek immediate medical attention for a first-time sex headache to rule out serious conditions. The diagnosis of coital cephalagia is primarily clinical, based on the patient's history and physical examination. The headache is typically described as explosive and can last from a few minutes to several hours.
- Treatment usually involves stopping sexual activity when symptoms begin and taking pain relievers like ibuprofen or naproxen.
- For prevention, medications such as indomethacin (25-50mg taken 30-60 minutes before sexual activity), propranolol (20-60mg daily), or triptans may be prescribed, as suggested by 1. However, it's essential to note that the provided evidence does not directly address coital cephalagia, but rather migraine and coital angina.
- The study by 2 discusses coital angina, which is angina that occurs immediately after sexual activity, and advises patients who experience postcoital angina to use nitrates and call emergency services if the angina persists.
- In contrast, coital cephalagia is a primary headache disorder, likely caused by increased blood pressure and heart rate during sexual arousal leading to blood vessel dilation, as seen in other headache disorders discussed in 1. Lifestyle modifications like changing positions during sex, being more passive, or controlling the buildup to orgasm may help reduce the occurrence of coital cephalagia.
- While often resolving on their own within months, recurrent episodes warrant medical evaluation to rule out underlying conditions and develop an effective treatment plan.
From the Research
Definition and Classification of Coital Cephalagia
- Coital cephalagia, also known as headache associated with sexual intercourse, can be divided into pre-orgasmic and orgasmic headaches 3, 4.
- Pre-orgasmic headache starts as a dull bilateral ache and increases with sexual excitement, while orgasmic headache has a sudden, intense character and occurs at orgasm 4.
- Some authors also specify a postural type of headache that develops after coitus 4.
Causes and Pathophysiology
- The cause of headaches related to sexual activity can range from benign to life-threatening 3.
- Basilar artery dissections and aneurysms should be considered in patients with sudden-onset headaches during orgasm due to the dynamics of cerebral blood flow during sexual intercourse 3.
- The pathophysiology of primary headache associated with sexual activity (PHASA) remains not fully understood 5.
Diagnosis and Management
- A thorough workup, including imaging and possibly lumbar puncture, is indicated to rule out potentially life-threatening etiologies such as subarachnoid hemorrhage, reversible cerebral vasoconstrictive syndrome (RCVS), vasospasm, and dissection 3, 5.
- PHASA can be treated preemptively with indomethacin and triptans administered prior to sexual activity, or treated prophylactically with beta-blockers, topiramate, and calcium channel blockers 5, 4.
- CGRP-targeted therapies may provide relief in PHASA, but there are no randomized controlled trials looking at specific efficacy for these therapies 5.
Clinical Manifestations and Treatment
- Benign coital cephalalgia is an acute headache that is time-related to sexual intercourse and can be successfully treated with propranolol hydrochloride 6.
- Indomethacin was effective in all patients as direct treatment, and propranolol was effective in patients to whom it was administered as preventive treatment 4.
- In some cases, coital cephalgia can result from more sinister causes, such as intraparenchymal and subdural haemorrhages 7.