Migraine and Sexuality: Are Migraine and Libido Linked?
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When it comes to sexual desire and performance, migraineurs - specifically female migraineurs - have long been getting a bad rap. For whatever reason, the “not tonight, honey…. I have a headache” cliché has transmogrified into a widely held assumption that females with migraine are hyposexual. Low on libido. Frigid “ice queens” who prefer to avoid sexual activity.
Taking this assumption at face value, one immediately is confronted by the obvious question: why? Why exactly should the 28 million American females with migraine have a lower level of sexual desire and performance than their migraine-free counterparts? As no plausible answer immediately springs to mind, it must be that in support of this sweeping assumption there exists a solid foundation of supportive scientific evidence from well-conducted research and a clear consensus from “the experts”. True?
Well…not really. While the peer-reviewed medical literature contains many articles indicating that migraine negatively impacts quality of life, and while some investigators have reported that this negative impact extends to sexual desire and performance, there is accumulating evidence to refute the notion that female migraineurs are “hyposexual”.
In 2006, researchers at Wake Forest University found higher levels of sexual desire in their research subjects with migraine than in those with tension-type headache. They hypothesized that this difference could be biologic in origin and specifically related to a protein, serotonin, that serves as one of the brain’s major neurotransmitters. Higher levels of serotonin correlate with low sexual desire. The selective serotonin reuptake inhibitors (SSRIs), medications that elevate serotonin levels and are commonly used to treat anxiety and depression, are well known to decrease libido and inhibit orgasm. In migraine low levels of serotonin are the rule.
In a separate study published in the journal Cephalalgia in 2013, well over half of the female migraineurs surveyed reported that sexual activity relieved or terminated their episodes of acute migraine. A third of the migraine group reported specifically using sex to treat their acute migraine headaches. The investigators hypothesized that this positive therapeutic effect of sexual activity and orgasm resulted from the consequent release of endorphins. In addition, noting that orgasm produces an increase in brain serotonin, they took the Wake Forest group’s hypothesis a step further by suggesting that an increased “sex drive” in those with migraine, a disorder commonly associated with low levels of serotonin in the brain, might reflect the brain’s quest to rectify that deficiency through sexual activity.
In a 2018 clinic-based study involving 200 heterosexual and sexually active females with migraine presenting to a university-based headache clinic and 200 migraine-free females matched for age, race/ethnicity, body mass index (BMI) and educational, social, economic and marital status, my colleagues and I found that the headache clinic patients with episodic migraine reported a higher libido, a higher monthly frequency of sexual intercourse and a higher likelihood of intercourse resulting in orgasm. All participants completed the Female Sexual Function Index (FSFI), a 6-aspect measure of sexual desire, arousal, lubrication, orgasm, satisfaction and pain. The mean score for the episodic migraine clinic patients was significantly higher than that recorded from the migraine-free control group. Similar to results from the 2013 Cephalalgia study, 25% of the migraine patients reported successfully using intercourse resulting in orgasm to terminate a migraine attack.
In a subsequent study whose results will be presented at the 2023 annual scientific meeting of the American Headache Society, we sought to confirm the results of our 2018 study and to eliminate any selection bias introduced by our having assessed only migraine patients actively under care in our headache clinic. We evaluated 150 female migraine patients from our clinic, 100 migraine-free but otherwise matched controls and 67 individuals with migraine selected randomly from the general population. As with the 2018 study, all participants completed the FSFI. Bot the clinic-based migraine group and the general population migraine group recorded mean FSFI scores significantly higher than that of the migraine-free control group. In this study as well as our 2018 study, mean FSFI scores in the subgroup of patients with chronic migraine were significantly lower than what was recorded from the episodic migraine subgroup.
Summing up…
While the results from published research are conflicting, there does not exist convincing evidence that females with episodic migraine have a lower libido or lower levels of sexual performance than females free of migraine. If anything, at least for many females with episodic migraine, it is precisely the opposite.
As with quality of life generally, those females with a greater migraine burden – and specifically those with chronic migraine – appear to have lower libido and lower levels of sexual performance than either females with episodic migraine, or females who are migraine-free.
For many female (and male) migraineurs, intercourse and orgasm may serve as a means of reducing or terminating acute migraine headache, and many within this fortunate group specifically use sex as a treatment for acute migraine.
Related to the last point, is the opposite also true? Can sexual activity and orgasm trigger migraine? Any strenuous physical activity can serve as a migraine trigger for some individuals, but only a very small percentage of migraineurs specifically identify sex as a trigger. Of note, recurrent episodes of sudden, severe and brief duration headache occurring just prior to or during orgasm is highly suggestive of so-called “primary headache associated with sexual activity”, a primary headache disorder that is the topic of this issue’s “Doctor on Call” (page 22).
In conclusion, as with most matters sexual the association between migraine and sexual desire/activity/performance is complex and multifaceted. In terms of libido (and no matter how one chooses to define or measure that elusive noun), being female and having migraine neither guarantees one will be a voracious sexual superstar nor condemns one to Arctic sexual frigidity . For many, an acute migraine episode will remove all appetite for sexual intercourse quite effectively, whereas for others intercourse and orgasm may act as a reliable alternative to use of medication for treating the episode. Suffice it to say that if you have migraine, if your headache disorder is adversely impacting your quality of life, and if at least a portion of that reduction involves your sex life, it is clearly time to seek advice and treatment from a healthcare provider experienced in the management of migraine.
John F Rothrock, MD
