What causes headaches during sexual intercourse?

Headache with Sexual Intercourse

Headaches during sexual intercourse are most commonly benign primary headaches, but you must immediately rule out life-threatening causes—particularly subarachnoid hemorrhage, basilar artery dissection, and reversible cerebral vasoconstriction syndrome—with urgent neuroimaging before considering this a benign condition. 1, 2

Immediate Diagnostic Priorities

Obtain an urgent non-contrast head CT immediately to exclude subarachnoid hemorrhage (SAH), as thunderclap headache during sexual activity is a red flag requiring emergency evaluation. 1

Critical Red Flags Requiring Emergency Workup:

• First or worst headache of life 1
• Thunderclap onset (sudden, severe, maximal intensity within seconds to minutes) 1, 3
• Any neurological deficits (focal signs, altered mental status, neck stiffness) 1
• Headache persisting beyond 24 hours 1
• First occurrence in patients over 40 years old 1

Imaging Algorithm:

• If presenting <6 hours from onset: Non-contrast head CT on high-quality scanner with board-certified neuroradiologist interpretation 1
• If CT negative but high suspicion: Proceed to lumbar puncture with spectrophotometric analysis for xanthochromia 1
• If both CT and LP negative but suspicion remains: Consider digital subtraction angiography (DSA) to diagnose cerebral aneurysm, dissection, or reversible cerebral vasoconstriction syndrome (RCVS) 1

Critical pitfall: Do not assume benign primary headache without imaging, as basilar artery dissection and SAH can present identically to benign primary headache associated with sexual activity (PHASA). 1, 2 Approximately 10-43% of SAH patients experience sentinel headaches before catastrophic rupture. 1

Clinical Presentation Patterns

Once life-threatening causes are excluded, primary headache associated with sexual activity typically presents in two distinct patterns:

Pre-orgasmic (Progressive) Type:

• Dull, bilateral headache that progressively intensifies as sexual excitement increases 3, 4
• Often described as tension-type quality 3

Orgasmic (Explosive) Type:

• Sudden, severe headache at or around orgasm 3, 4
• Primarily occipital location, though can be diffuse and bilateral 3
• Resembles thunderclap headache presentation 3, 4

Combined Type:

• Some patients experience both progressive and explosive features 4

Essential Clinical Assessment

Document the following high-risk features during history:

• Timing: Exact relationship to sexual activity phases 5
• Character: Dull/progressive vs. thunderclap/explosive 3
• Location: Occipital, diffuse, unilateral, or bilateral 3
• Duration: Seconds, minutes, hours, or days 5
• Associated symptoms: Nausea, vomiting, photophobia, neck stiffness 5

Perform focused neurological examination including:

• Focal neurological signs 1
• Neck stiffness and limited neck flexion 1
• Mental status and memory assessment 1
• Coordination testing 1
• Fundoscopic examination if available 1

Pathophysiology

The mechanisms underlying sexually-induced headaches include:

• Mechanical factors: Increased intracranial pressure from Valsalva maneuver during orgasm 6
• Autonomic dysregulation: Sudden sympathetic nervous system activation during sexual excitement and orgasm 6
• Trigemino-vascular system activation: Triggered by both mechanical factors and chemical mediators (oxidative stress, inflammatory parameters) 6

Sexual activity requires 2-3 METs during pre-orgasmic stage and 3-4 METs during orgasmic stage, comparable to moderate-intensity exercise. 6

Common Comorbidities

Primary headache associated with sexual activity frequently co-occurs with:

• Migraine 3, 4
• Tension-type headache 3
• Exertional headache 3
• Hypertension 3

History of atopic disease has been identified as a risk factor. 6

Treatment Approach

Acute/Preemptive Treatment:

Administer indomethacin or triptans 30-60 minutes prior to sexual activity for patients with predictable, recurrent episodes. 3

Prophylactic Treatment:

For patients with frequent episodes (>2 per week):

• Beta-blockers (propranolol 40 mg/day has shown dramatic improvement in case reports) 3, 7
• Topiramate 8, 3
• Calcium channel blockers 3
• CGRP-targeted therapies may provide relief based on emerging case reports, though no randomized controlled trials exist 3

Treatment duration: Maintain prophylaxis for 6 months, then reassess. 7 Many patients experience self-limited courses with spontaneous resolution. 3, 4

Additional Therapeutic Options:

Recent advances include:

• Greater occipital nerve injection 8
• Manual therapy 8
• Progesterone 8

Clinical Course and Prognosis

Primary headache associated with sexual activity typically presents as:

• Discrete, recurrent events with bouts that self-resolve 3
• Relapsing-remitting pattern in some patients 3
• Chronic continuation in a minority 3
• Lifetime prevalence: 1-1.6% in general population 7

The prognosis is generally excellent for primary headache associated with sexual activity, with most patients experiencing self-limited disease. 4 However, some patients may have a prolonged course requiring ongoing management. 4

Safety-Net Instructions

Patients must return immediately for:

• Worsening headache intensity 1
• New neurological symptoms (weakness, vision changes, confusion, seizures) 1
• Persistent headache beyond 24 hours 1

Do not discharge without clear written instructions emphasizing these warning signs. 1