One week back, a young gentleman aged about 25 years came to my clinic along with his life partner with a complaint of getting a severe headache whenever he participates in sexual intercourse with his wife. We rarely receive cases of this sort for consultation. His wife too was so pathetic and emotionally deprived about her husband’s predicament.
Sex headache is precipitated by sexual excitement. The pain usually begins as a dull bilateral headache that suddenly becomes intense at orgasm. An orgasm is the height or peak of sexual arousal when the body releases sexual tension and pressure. It involves very intense feelings of pleasure in the genitals that are external and internal sex organs and glands and throughout the body. An orgasm usually lasts a few seconds and feels very good. Finishing, or having an orgasm, is a pleasurable climax that involves intense feelings in the genitals and body, accompanied by a release of tension and a sense of happiness and relaxation from endorphins. Endorphins are natural pain-relieving peptides produced in the brain, acting as neurotransmitters that create feelings of well-being and ecstasy. They are released in response to stress or pain, such as during exercise, and are often called the body’s “feel-good” chemicals because they bind to opioid receptors and block pain signals, while also boosting mood and reducing anxiety. The experience can include muscular contractions in the pelvic area and may result in a feeling of electrical tingling or “shattering” energy that radiates through the body. It is a highly individual experience that varies from person to person and even from one time to the next time, experienced by both males and female partners.
The headache can be prevented or eased by ceasing sexual activity before orgasm. Three types of sex headache are reported: a dull ache in the head and neck that intensifies as sexual excitement increases; a sudden, severe, explosive headache occurring at orgasm; and a postural headache developing after coitus that resembles the headache of low CSF pressure. Low cerebrospinal fluid (CSF) pressure, or intracranial hypotension, occurs when CSF volume is low, most often due to a leak from the meninges. The most prominent symptom is a headache that worsens when upright and improves when lying down. Other symptoms include nausea, vomiting, neck pain, tinnitus, and dizziness. The latter arise from vigorous sexual activity and is a form of low CSF pressure headache. Headaches developing at the time of orgasm are not always benign; 5-12% of cases of subarachnoid haemorrhage in which the main symptom is a sudden, severe “thunderclap” headache, precipitated by sexual intercourse. A subarachnoid haemorrhage (SAH) is a medical emergency where bleeding occurs in the space between the brain and the thin tissues covering it, known as the subarachnoid space.
Sex headache is reported by men more often than women and may occur it any time during the years of sexual activity. It may develop on several occasions in succession and then may not trouble the patient again, even without an obvious change in sexual activity. In patients who stop sexual activity when headache is first noticed, the pain may subside within a period of 5 min to 2 hours, in about half of patients. Usually, sex headache will subside within 6 months. About half of patients with sex headache have a history of exertional headache. Migraine is probably more common in patients with sex headache.
A sex headache can be a dull ache that builds with excitement or a sudden, severe “volatile” headache. When repeated headache occurs, it is recommended to consult a doctor, especially for severe or first-time episodes.
Classification of Sex Headaches
A dull ache in the neck and head that builds with sexual excitement is called a pre-orgasmic headache. An abrupt, severe headache that occurs just before or at the moment of orgasm is known as orgasmic headache, and post-orgasmic postural headache is that can occur after orgasm, potentially caused by a tear in the dural lining of the brain.
Causes
Primary headaches are benign and usually associated with sexual activity. Secondary headaches are those caused by an underlying condition, such as high blood pressure or issues with brain blood vessels. The brain blood vessels issues are called cerebrovascular disease, which involves conditions like stroke, aneurysm, which is an excessive localized swelling of the wall of an artery, and TIA (transient ischemic attacks caused by reduced blood flow (ischemia) or bleeding (haemorrhage). Causes include blood clots, plaque build-up, ruptured vessels, and structural problems, leading to symptoms like weakness, slurred speech, and severe headaches. Treatments focus on the specific condition and may involve medication like blood thinners or blood pressure medication, as well as other interventions.
Risk factors
Male gender, history of migraine, high blood pressure, and underlying conditions, such as cerebral arteriovenous malformations or other brain abnormalities. Cerebral arteriovenous malformations (AVMs) are a tangle of abnormal blood vessels in the brain, causing high-pressure blood flow directly from arteries to veins, bypassing the capillaries. This can lead to brain damage or bleeding (haemorrhage), and symptoms like seizures, headaches, and neurological issues like weakness or vision problems. Other brain abnormalities include conditions like large developmental venous anomalies, cavernous malformations, and moyamoya disease, which require different treatment plans. Moyamoya disease is a rare, progressive cerebrovascular disorder where arteries at the base of the brain narrow, reducing blood flow and leading to strokes. The Japanese term “moyamoya” (meaning “puff of smoke”) describes the tangled, fragile network of new blood vessels that attempt to compensate for the blockage. Symptoms can include transient ischemic attacks (TIAs), stroke, headaches, seizures, and progressive decline in cognitive function.
Expert advice
If it is the first time experiencing a severe or “explosive” headache during sex and the headache is severe and does not go away while having vomiting or visual disturbances, to rule out any underlying medical conditions it is advised to consult an expert. Management of the sex headache and related issues will be discussed in the next episode. (To be concluded).
