From the Research
Imaging for a climax headache should typically involve a CT scan without contrast as the first-line imaging study, due to its availability and speed in emergency settings, as supported by the most recent and highest quality study 1. When evaluating patients with severe, sudden-onset headaches during sexual activity, it is crucial to rule out serious conditions like subarachnoid hemorrhage or other vascular abnormalities.
- The decision to image should be based on clinical presentation, with red flags including first or worst headache of life, abnormal neurological examination, or headaches that persist beyond 24 hours.
- If the CT is negative but clinical suspicion remains high, a lumbar puncture may be performed to check for blood in the cerebrospinal fluid.
- In cases where more detailed imaging is needed, an MRI with or without contrast and/or MR angiography (MRA) may be ordered to evaluate the cerebral vasculature more thoroughly.
- The study by 1 found that CT undertaken within 6 hours is highly accurate and likely to be sufficient to rule out SAH, with a sensitivity of 98.7% and specificity of 100%.
- Additionally, the study by 1 suggests that the CT-LP pathway is highly sensitive for detecting SAH and some alternative diagnoses, although LP results in some false positive results.
- It is essential to note that although most climax headaches are benign and self-limiting, approximately 15% may be associated with underlying vascular pathology that requires immediate treatment.
- For benign climax headaches without concerning features, prophylactic medications like indomethacin (25-50mg taken 30-60 minutes before sexual activity) or daily propranolol (20-60mg twice daily) may be prescribed while avoiding imaging if not clinically indicated, as suggested by previous studies 2, 3, 4, 5.