What is the diagnosis and management for a young male patient with a 3-4 week history of severe headaches after ejaculation, accompanied by nausea and poor appetite, with a history of anxiety, and lab results showing leukocytosis (elevated White Blood Cell Count), neutrophilia, and elevated hemoglobin and hematocrit levels?

Primary Headache Associated with Sexual Activity (PHASA) with Concerning Features Requiring Urgent Evaluation

This patient requires urgent neuroimaging to rule out life-threatening secondary causes of post-coital headache, particularly reversible cerebral vasoconstriction syndrome (RCVS), arterial dissection, or subarachnoid hemorrhage, before considering a diagnosis of benign primary headache associated with sexual activity.

Immediate Diagnostic Priorities

Critical Secondary Causes to Exclude

The 3-4 week duration of severe "thunderclap" headaches occurring at ejaculation mandates urgent evaluation for dangerous etiologies 1, 2, 3:

• Reversible cerebral vasoconstriction syndrome (RCVS): Presents with recurrent thunderclap headaches during sexual activity and shows segmental vasoconstriction on imaging 1, 2
• Arterial dissection: Basilar or vertebral artery dissection can present as sudden-onset orgasmic headache 3
• Subarachnoid hemorrhage: Must be excluded in any thunderclap headache presentation 2
• Cerebral vasospasm: Can mimic benign headache patterns 2

Required Imaging Workup

Obtain brain MRI with magnetic resonance angiography (MRA) immediately 1, 2:

• MRA is essential to visualize cerebral vasculature and detect segmental vasoconstriction characteristic of RCVS 1
• Standard brain MRI alone may miss vascular abnormalities 2
• If MRI/MRA is negative but clinical suspicion remains high, consider CT angiography 2
• Lumbar puncture may be necessary if subarachnoid hemorrhage cannot be excluded by imaging 3

Laboratory Findings Interpretation

The elevated hemoglobin (18.9), hematocrit (53.7), and RBC count (6.13) suggest polycythemia, which increases blood viscosity and thrombotic risk [@general medical knowledge]:

• This finding raises concern for increased stroke risk and cerebrovascular events
• The mild leukocytosis (WBC 11.3) with neutrophilia could represent stress response or underlying inflammatory process
• These abnormalities do not explain the headache directly but increase urgency for vascular imaging
• Polycythemia workup (JAK2 mutation, erythropoietin level, sleep study for hypoxia) should follow acute headache evaluation

Clinical Features Distinguishing Primary vs. Secondary Headache

Features Suggesting Benign PHASA [@9@, @11@, @13@]:

• Bilateral occipital location
• Duration of 2 hours or less per episode
• Recurrent pattern over weeks to months
• No neurological deficits between episodes

Red Flags in This Case Requiring Investigation:

• Persistent nausea and poor appetite for 3-4 weeks (atypical for benign PHASA) 2
• First occurrence in this patient (new-onset always requires workup) 2
• Severity described as "very severe" (concerning for secondary cause) [@10@, @12@]
• Associated systemic symptoms beyond isolated headache [@11@]

Management Algorithm

Step 1: Urgent Evaluation (Within 24-48 Hours)

1. Neuroimaging with MRI/MRA to exclude RCVS, dissection, aneurysm [@10@, 2,3]
2. Detailed headache characterization: exact timing relative to orgasm (pre-orgasmic vs. orgasmic), quality (explosive vs. gradual), duration, associated symptoms [@11@, @13@]
3. Cardiovascular assessment: blood pressure measurement, cardiac examination (hypertension is comorbid with PHASA) 2
4. Substance use history: recent vasoactive drug exposure including decongestants, stimulants, cannabis [@10@]

Step 2: If Imaging is Negative - Diagnosis of Primary PHASA

Only after excluding secondary causes can benign PHASA be diagnosed [@11@, 4]:

Acute/Preemptive Treatment Options:

• Indomethacin 25-50 mg taken 30-60 minutes before sexual activity (most effective preemptive therapy) 2
• Triptans administered prior to sexual activity (alternative preemptive option) 2

Prophylactic Treatment for Recurrent Episodes:

• Propranolol 40-80 mg daily (first-line prophylaxis with strong evidence) [@9@, 2]
• Alternative prophylactic agents: topiramate, calcium channel blockers [@11@]
• Treatment duration: typically 6 months, then reassess [@9@]

Step 3: Address Polycythemia

After acute headache evaluation:

• Hematology referral for polycythemia workup
• Consider therapeutic phlebotomy if primary polycythemia confirmed
• Evaluate for secondary causes: sleep apnea, chronic hypoxia, testosterone supplementation

Common Pitfalls to Avoid

1. Do not reassure and discharge without imaging when thunderclap headache is described, even if examination is normal [@10@, 2,3]
2. Do not attribute symptoms to anxiety without excluding organic pathology first, despite anxiety history 2
3. Do not miss RCVS - it can present identically to benign orgasmic headache but requires specific treatment to prevent stroke 1, 2
4. Do not overlook the polycythemia - this increases thrombotic risk and may contribute to cerebrovascular complications [@general medical knowledge]

Prognosis and Follow-Up

If imaging confirms benign PHASA 5, 2, 4:

• Condition typically self-resolves over weeks to months
• Prophylactic treatment highly effective (dramatic improvement reported in 2 weeks with propranolol) 5
• Recurrence possible but usually responds to same treatment 5
• Long-term follow-up shows no serious intracranial disorders develop in benign cases 4

The key clinical decision point is obtaining urgent neuroimaging before any treatment initiation - the 3-4 week duration of severe symptoms with systemic features (nausea, poor appetite) and polycythemia creates sufficient concern that secondary causes must be definitively excluded. 1, 2, 3