Headache After Sex: Causes and Management
Post-coital headache is most commonly a benign primary headache disorder (Primary Headache Associated with Sexual Activity), but urgent evaluation with neuroimaging is mandatory at first presentation to exclude life-threatening secondary causes like subarachnoid hemorrhage, reversible cerebral vasoconstriction syndrome (RCVS), or arterial dissection. 1, 2
Immediate Evaluation Required
When a patient presents with headache associated with sexual activity, you must first rule out dangerous secondary causes:
- Obtain urgent neuroimaging (MRI brain preferred, CT if abrupt onset) to exclude subarachnoid hemorrhage, RCVS, vasospasm, and arterial dissection 1, 2
- "Thunderclap" presentation (sudden-onset, severe headache) particularly warrants immediate imaging and possible CSF examination 1, 2
- Headache brought on by sexual activity is a red flag requiring diagnostic testing 2
Clinical Presentation of Primary Headache Associated with Sexual Activity (PHASA)
Once secondary causes are excluded, PHASA typically presents with these characteristics:
- Pain location: Primarily occipital, diffuse, and bilateral 1, 3
- Timing: Either a dull headache that progresses with sexual excitement, or an explosive headache at or around orgasm 1, 3
- Duration: Mean duration approximately 21 minutes, though variable 3
- Pattern: Discrete, recurrent events that typically self-resolve, though may relapse and remit or continue chronically 1
- Demographics: More common in males, typically starting in the third decade of life 3
Important Comorbidities to Assess
PHASA commonly coexists with:
- Migraine (present in approximately 38% of cases in one series) 1, 3
- Tension-type headache 1
- Exertional headache 1
- Arterial hypertension (present in 23% of cases in one series) 3
Treatment Approach
Acute/Preemptive Treatment
For patients who can anticipate sexual activity, preemptive treatment administered 30-60 minutes prior is most effective:
- Indomethacin (preemptive dosing before sexual activity) is the most established treatment 1, 4, 5
- Triptans administered prior to sexual activity can be effective 1
- Critical limitation: Acute treatment should be limited to no more than twice weekly to prevent medication-overuse headaches 6
- Frequent triptan use (≥10 days/month) or NSAID use (≥15 days/month) can cause rebound headaches 6, 7
Prophylactic Treatment
For patients with frequent episodes, daily prophylactic therapy is appropriate:
- Beta-blockers (first-line prophylactic option) 1
- Topiramate 1, 4
- Calcium channel blockers 1
- Emerging evidence suggests CGRP-targeted therapies may provide relief, though no randomized controlled trials exist yet 1
Medications to Avoid
Never prescribe opioids or butalbital-containing medications due to risks of dependency and rebound headaches 6, 8, 7
Counseling and Non-Pharmacological Management
Patient counseling plays an essential role in management 3:
- Reassure patients that PHASA is typically benign once secondary causes are excluded 1
- Patients may have difficulty explaining the problem and may limit sexual activity unnecessarily 3
- Discuss that episodes are typically self-limited and often resolve spontaneously over time 1
- Consider less strenuous sexual positions or activities if exertion appears to be a trigger 4
Common Pitfalls to Avoid
- Failing to image at first presentation: Always obtain neuroimaging with the first episode, as secondary causes can be life-threatening 1, 2
- Overprescribing acute medications: Limit to twice weekly maximum to prevent medication-overuse headache 6
- Using opioids or butalbital: These carry dependency risks and cause rebound headaches 6, 8
- Dismissing patient concerns: The condition can significantly impact quality of life and relationships; take it seriously 3