What causes headaches during sexual intercourse and how are they treated?

Headache with Sexual Intercourse: Causes and Treatment

Immediate Action Required

First, you must urgently obtain a non-contrast head CT to rule out subarachnoid hemorrhage (SAH), as thunderclap headache during sexual activity is a medical emergency that can indicate life-threatening conditions including SAH, basilar artery dissection, or reversible cerebral vasoconstriction syndrome (RCVS). 1, 2

Emergency Evaluation Protocol

• If presenting <6 hours from onset: Perform non-contrast head CT on a high-quality scanner with interpretation by a board-certified neuroradiologist 1
• If presenting >6 hours from onset OR with any neurological deficit: Perform non-contrast head CT immediately, then proceed to lumbar puncture with spectrophotometric analysis for xanthochromia if CT is negative 1
• If CT and LP are negative but suspicion remains high: Consider digital subtraction angiography to diagnose or exclude cerebral aneurysm, dissection, or RCVS 1

Red Flags Requiring Immediate Workup

Document these high-risk features that mandate emergency evaluation 1:

• First or worst headache of life
• Thunderclap onset (sudden, severe)
• Headache persisting beyond 24 hours
• Any neurological deficits
• Neck stiffness or fever
• First occurrence in patients over 40 years old

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.

Causes of Sexual Activity-Associated Headache

Secondary (Life-Threatening) Causes

• Subarachnoid hemorrhage from ruptured aneurysm 1, 2
• Basilar artery dissection 2
• Reversible cerebral vasoconstriction syndrome (RCVS) 1, 3
• Cerebral vasospasm 3

Primary Headache Associated with Sexual Activity (PHASA)

Once life-threatening causes are excluded, PHASA is a benign condition with lifetime prevalence of 1-1.6% in the general population 4. PHASA presents in two patterns 3:

• Pre-orgasmic (dull type): Progressive dull headache that increases with sexual excitement
• Orgasmic (explosive type): Sudden, severe headache at or around orgasm

Typical characteristics 3, 4:

• Pain is primarily occipital, diffuse, and bilateral
• Duration typically 2 hours but can vary
• Commonly comorbid with migraine, tension-type headache, exertional headache, and hypertension
• Episodes are discrete and recurrent, with bouts that typically self-resolve

Treatment Approach

Acute/Preemptive Treatment (Taken 30-60 Minutes Before Sexual Activity)

Indomethacin 25-50 mg is the first-line preemptive treatment 3, 5, 6

Alternative preemptive option:

• Triptans administered prior to sexual activity 3

Prophylactic Treatment (For Frequent Episodes)

Propranolol is the most established prophylactic agent 3, 4, 6:

• Start with propranolol 40 mg/day 4
• Effective in preventing recurrent episodes
• Treatment typically maintained for 6 months 4

Alternative prophylactic options 3, 5:

• Beta-blockers (metoprolol as alternative to propranolol)
• Topiramate 50 mg/day (particularly useful when indomethacin and propranolol are contraindicated, such as in patients with gastritis or diabetes) 5
• Calcium channel blockers

Emerging option:

• CGRP-targeted therapies may provide relief based on case reports, though no randomized controlled trials exist yet 3

Treatment Selection Algorithm

1. For occasional episodes: Use preemptive indomethacin 25-50 mg taken 30-60 minutes before sexual activity 3, 6
2. For frequent episodes: Initiate prophylactic propranolol 40 mg/day for 6 months 4
3. If contraindications to indomethacin (gastritis) or propranolol (diabetes): Use topiramate 50 mg/day prophylactically 5
4. If initial prophylaxis fails: Consider alternative beta-blockers, calcium channel blockers, or topiramate 3, 5

Follow-Up and Monitoring

• Reassess in 2 weeks after initiating prophylactic treatment 4
• Continue successful prophylaxis for 6 months 4
• Patients must return immediately for worsening headache, new neurological symptoms, or persistent headache beyond 24 hours 1

Do not discharge without clear safety-net instructions, as recurrence with different characteristics may indicate secondary pathology 1.