What is the treatment for coital cephalagia (headaches during or after sexual activity)?

Treatment for Coital Cephalalgia (Headaches During or After Sexual Activity)

Indomethacin taken before sexual activity is the first-line treatment for primary coital cephalalgia, with propranolol recommended as an effective prophylactic option for recurrent cases. 1, 2

Classification and Diagnosis

• Coital cephalalgia (sexual headache) can be primary or secondary, with primary being benign but secondary potentially indicating serious underlying conditions 1
• Primary headache associated with sexual activity (PHASA) typically presents in two main forms:
  • Preorgasmic headache: Dull bilateral ache that increases with sexual excitement 2
  • Orgasmic headache: Sudden, intense "thunderclap" headache occurring at orgasm 2, 1
• Pain is primarily occipital, diffuse, and bilateral in nature 1

Diagnostic Evaluation

• Thorough workup including neuroimaging is essential to rule out potentially life-threatening secondary causes 1, 3
• "Red flags" requiring immediate investigation include:
  • First or worst headache of life
  • Sudden onset thunderclap headache
  • Persistent headache following sexual activity
  • Neurological symptoms (vision changes, weakness, etc.) 4, 3
• Secondary causes that must be excluded:
  • Subarachnoid hemorrhage
  • Arterial dissection (including basilar artery)
  • Reversible cerebral vasoconstriction syndrome (RCVS)
  • Intraparenchymal hemorrhage 3, 5, 1

Treatment Algorithm

Acute Treatment

• For isolated or infrequent episodes:
  • Indomethacin 25-50mg taken 30-60 minutes before sexual activity 2, 1
  • Triptans may be used as an alternative preemptive treatment before sexual activity 1

Prophylactic Treatment

• For recurrent episodes or when preemptive treatment is ineffective:
  • First-line: Propranolol 40-200mg daily (divided doses) 6, 2, 1
  • Alternative options:
    • Other beta-blockers
    • Topiramate
    • Calcium channel blockers (e.g., verapamil) 1
  • Emerging option: CGRP-targeted therapies may provide relief based on case reports, though randomized controlled trials are lacking 1

Management Considerations

• Patients should be advised to temporarily abstain from sexual activity during acute treatment phase 2
• Gradual resumption of sexual activity can be recommended once symptoms resolve and preventive medication is established 1
• Most cases of primary coital cephalalgia are self-limiting, but may follow a relapsing-remitting pattern or become chronic in some patients 1
• Comorbid conditions like migraine, tension-type headache, exertional headache, and hypertension should be identified and treated 1

Warning Signs Requiring Emergency Evaluation

• Headache that persists beyond 24 hours
• Accompanying neurological deficits (vision changes, weakness, etc.)
• Neck stiffness or fever
• First occurrence in patients over 40 years old
• Headache that awakens patient from sleep 4, 3, 5

Remember that while primary coital cephalalgia is typically benign, secondary causes can be life-threatening, making proper diagnosis crucial before initiating treatment.