Doctor on Call
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Charlotte, a 46 year old attorney who lives and works in Washington, DC writes:
I’ve had occasional migraines ever since I hit puberty at 13, but they rarely have required more than some ibuprofen and a cup of coffee to control, and they have never occurred during sex.
Three months ago my husband and I were having sex, and just as I began to climax I developed a horrible headache that for about five minutes was so intense I could barely speak. Over the next hour it gradually vanished, but a few days later the same thing happened, again during sex and again with a sudden, severe headache that started just as I was having an orgasm.
The same thing happened repeatedly over the next 4 or 5 weeks, and I finally went to see my PCP. She ordered a brain CT scan, and it was normal. She prescribed a medicine for me to take when I got the headache, but I’ve tried it twice and don’t think it made any real difference - the worst part of the headache lasts five minutes or less, and the headaches always have gone away entirely within 20 or 30 minutes without me doing or taking anything.
She has referred me to a neurologist, but my appointment is not for another two months. The headaches have made me so apprehensive that I’m hesitant to have sex, and when we do, I can’t relax enough to get into it. No orgasm, no headache… but also not much pleasure. My husband is getting frustrated, and I’m getting worried. Do I have a brain aneurysm that is going to burst? Will I ever be able to have normal sex again?
Miserable in Georgetown
The Doctor’s Reply:
Charlotte,
It is highly unlikely that your headaches are being caused by an aneurysm or any other ominous abnormality of the brain, and the odds are excellent that your ability to enjoy sex will return undiminished.
What you describe is highly characteristic of the somewhat cumbersomely named “primary headache associated with sexual activity (PHAwSA)”. More mellifluous and descriptive terms previously used for this diagnosis have included benign sexual headache, coital headache and orgasmic headache.
The headache of PHAwSA typically occurs at peak sexual excitement and often with orgasm itself. The headache is most typically “thunderclap” in character, reaching peak intensity rapidly or even immediately. It is one of the clinically benign causes of thunderclap headache.
The least benign cause of exertional thunderclap headache is a ruptured brain aneurysm, and in all instances of first-ever “orgasmic headache” subarachnoid hemorrhage from a ruptured aneurysm must be considered and excluded. The far more likely cause of orgasmic headache is PHAwSA, but the consequences of failing to diagnose aneurysmal subarachnoid hemorrhage (or one of the other causes of “secondary” exertional thunderclap headache) can be extremely grave.
In contrast to aneurysmal subarachnoid hemorrhage and the other “secondary” causes of thunderclap headache, PHAwSA tends to be of much shorter duration, with the severe intensity phase persisting for as little as a minute and, at times, followed by a much milder headache that on rare occasions may hang on for as long as 72 hours before fading away.
Even more distinctive is the tendency for the thunderclap headache of PHAwSA to recur repeatedly over a period of months or even longer. This pattern would be extremely unusual with a brain aneurysms, a tear in the lining of one of the arteries supplying the brain (dissection), a blood clot within a major cerebral vein or virtually any other conceivable structural abnormality involving the brain.
Although PHAwSA is classified as a primary headache disorder, with the headaches arising in and of themselves and not as a symptom of another disorder, there does appear to be a potential link to migraine: PHAwSA occurs more commonly in migraineurs than in non-migraineurs. PHAwSA is not specific to penetrative heterosexual intercourse and instead can be caused by any type of sexual activity. Studies have shown that over half of all cases of PHAwSA run a chronic course that persists for at least a year, but in the author’s experience it has been unusual for a treated patient to continue with these headaches for more than a 2 or 3 months.
Great, you say. I have a diagnosis, but now do I have to tell my husband that we can’t have sex for at least a few months…maybe even a year or more?
Although there exists no truly evidence-based therapy for PHAwSA, there are numerous case reports and case series published in the medical literature suggesting that “anticipatory” or conventional prophylactic (prevention) therapy with any one of a number of medications may be useful. With anticipatory therapy, physicians often prescribe one of the oral triptans or indomethacin (an old and long-generic non-steroidal anti-inflammatory drug,) to be taken about 30 minutes prior to sexual activity. Prophylactic therapy with, again, indomethacin or with a beta blocker (propranolol, metoprolol, nadolol), a calcium channel blocker or topiramate have been reported to be effective.
If the patient’s baseline frequency of sexual activity is relatively low, it may make more sense to start with anticipatory therapy. If the baseline frequency is higher, scheduled prophylactic therapy may be more appropriate. What doesn’t really make sense is to try to treat these headaches with acute/as needed therapy. The duration of the intense headache phase is simply too short for any orally administered drug – or even something as fast-acting as injectable sumatriptan – to do any real good.
In the editor’s experience, a relatively low-dose of indomethacin taken three times daily typically has been effective in terminating the headache episodes. In all of the patients he has treated for PHAwSA, there has been no recurrence of the headaches once they have stopped. The optimal duration of prevention therapy for PHAwSA is unknown, but if scheduled indomethacin is the treatment utilized, considerations of tolerability and potential injury to the gastrointestinal, tract or kidneys would seem to call for a “the shorter the better” approach.
So, the news is good, Charlotte. Go ahead and see your neurologist to confirm the diagnosis, and if PHAwSA is indeed the cause of your headaches, your medical (and sexual) prognosis is excellent.
