Doctor on Call
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Madeline, a 28-year-old restaurant manager who lives in Manhattan Beach, California writes:
I’ve had occasional migraine headaches since I was about 13, but they are so infrequent that they never really bother me. I just take some Advil, go to bed early and sleep them off.
About three months ago my migraines took a drastic change for the worse, and they literally are threatening to ruin my life. These headaches are entirely different than my usual migraines, and what’s really weird is that I only get them when I’m having sex with my boyfriend.
We’ve been living together for over a year now and were planning to get married this summer. Until three months ago our sex life was fine, and then one night while we were making love I had an orgasm that was immediately followed by the worst headache of my life. The pain was sudden and severe, like someone hit me with a baseball bat. I seldom cry, but that headache had me weeping uncontrollably. My boyfriend was so concerned that he called 911… which made me feel foolish because by the time the paramedics delivered me to the ER my headache was largely gone. The doctors still did a number of tests, including brain scans, but in the end they really didn’t have much to say.
Over the next few weeks I had 6 more of these same sudden and severe but brief migraines, always during sex and always when I was aroused and either about to have an orgasm or having one. The pain is so horrible that now I’m hesitant to have sex, and when we do have sex, I’m too distracted by the fear of having another headache to become aroused. It’s become so bad that we’ve not had sex for over a month. I’m not happy, my fiancé’s not happy and I’m worried that our relationship will fall apart.
Frustrated and Fearful in Manhattan Beach.
The Doctor’s Reply:
Madeline,
What you are describing is not migraine or, fortunately, a serious cause of so-called “thunderclap headache” such as a bleeding brain aneurysm. This is a classic description of another much less common but quite primary vivid headache disorder: primary headache associated with sexual activity. For obvious reasons, in the past it was often referred to as “orgasmic” or pre-orgasmic” headache.
In contrast to migraine, this headache disorder occurs somewhat more commonly in males than females. The pain is typically “thunderclap” in onset, the headache reaching peak intensity immediately as orgasm occurs or building rapidly in intensity in parallel with increasing pre-orgasmic arousal. Although some residual head pain may be present for hours or even up to several days, the high intensity head pain tends to subside within minutes to an hour or so. There rarely occurs the nausea, light sensitivity or aura symptoms that so often accompany migraine.
Especially with the first episode of thunderclap headache occurring during sexual arousal/orgasm, care must be taken to exclude aneurysmal subarachnoid hemorrhage, a diffuse constriction of brain blood vessels known as reversible cerebral vasoconstriction syndrome (RCVS), spinal fluid leak or another “secondary” cause of the headache. With repetitive episodes of orgasmic headache that is sudden and severe but brief in duration, however, the diagnosis of “primary” headache associated with sexual activity is secure.
The cause of this symptomatically dramatic headache disorder is unknown. While investigators have reported it to occur more frequently in individuals with migraine, primary headache associated with sexual activity commonly occurs in males and females who have no history of migraine whatsoever.
Although this headache disorder often resolves spontaneously, in about 40% of cases the episodes of pre-orgasmic/orgasmic headache may persist for a year or more. Fortunately, treatment with indomethacin (a nonsteroidal anti-inflammatory drug), propranolol (a beta-blocker) and/or a triptan may be quite effective in preventing the headaches. Once the headaches have been suppressed for a few weeks or months, treatment usually may be discontinued without recurrence of the headaches.
In short, Madeline, this headache disorder is, without question, a major annoyance, but it is not a “forever” condition, and most often the unwelcome headaches can be brought to a rapid stop with appropriate treatment.
For confirmation of the diagnosis and treatment, see one of the excellent headache specialists who practice in your area…and don’t cancel the honeymoon.
