Not Tonight, Dear! It May Cause a Headache

Abstract & Commentary

By Dara G. Jamieson, MD, Associate Professor of Clinical Neurology, Director, Headache Center, Weill Medical College of Cornell University; Dr. Jamieson is a consultant for Boehringer Ingelheim and Merck, and is on the speaker's bureau for Boehringer Ingelheim, Merck, Ortho-McNeil, and Pfizer.

Synopsis: Benign headaches associated with sexual activity are either a dull aching pain prior to orgasm or severe pain at orgasm. They can be prevented with indomethacin, beta-blockers, or triptans.

Source: Frese A, Rahmann A, Gregor N, et al. Headache associated with sexual activity: prognosis and treatment options. Cephalalgia 2007 Oct 5 [Epub ahead of print].

Headache associated with sexual activity (HSA) can be distressing to the patient and perplexing to the physician. The cause of a HSA may be readily apparent in patients taking nitric oxide donors, such as sildenafil citrate, for erectile dysfunction. Rarely, a cerebrovascular cause of HSA, such as hemorrhagic or ischemic stroke, is diagnosed based upon characteristics of the headache and other accompanying neurological symptoms. A postural HSA may be related to leakage of cerebrospinal fluid associated with sexual activity. Although HSA can be frightening, especially when it occurs repetitively, its cause is generally benign. The International Headache Society defines two types of HSA: a preorgasmic headache with dull head and neck pain increasing with sexual excitement (HSA type 1); and a sudden, severe, explosive orgasmic headache (HSA type 2).

The aim of this study of HSA by Frese and colleagues was to provide data on the prognosis and treatment options of HSA in an outpatient headache clinic at the University of Münster. A paper published in 2003 by the same group described the features of HSA in headache clinics at two academic medical centers in Germany.1 The diagnosis of HSA was made after neuroimaging (MRI/MRA, CT/CTA) and/or lumbar puncture in 78 patients between 1996 and 2004. Eleven patients had HSA type 1 and 49 had HSA type 2, without demographic differences between patients with the two headache types. There were 47 men and 13 women. The mean age at baseline was 39.8 ± 12.3 years, with a mean age at onset of 36.7 ± 11.7 years. Sixty patients were followed up by telephone between 2003 and 2006, at least 12 months after the first interview. The patients were asked about the course of the headaches and the effectiveness of treatment. On average, the second interview was performed 35.9 months after the first examination. Of the 45 patients who had suffered from single attacks or bouts prior to baseline examination, 37 had no further attacks. Seven patients suffered from at least one further bout, with an average duration of 2.1 months. One patient developed a chronic course of the disease after an episodic start. Of the 15 patients with chronic disease at the first examination, seven were in remission and five had ongoing attacks at follow-up. Ten patients received indomethacin for preemptive (prior to sexual activity) therapy, with good results in nine patients. Eighteen patients received beta-blockers for prophylaxis, with good results in 15 patients.

This study found that episodic HSA occurs in approximately three-quarters, and chronic HSA in approximately one-quarter, of patients with headache associated with sexual activity. Patients with chronic HSA were older at onset. Even with chronic HSA, the prognosis is favorable, with remission rates of 69% during an observation period of three years. For patients with longer-lasting bouts or with chronic HSA, prophylactic treatment with beta-blockers or preemptive therapy with indomethacin often is successful.


Headaches associated with sexual activity range from distressing (HSA type 1) to terrifying (HSA type 2); however, their recognition as a benign headache disorder should reassure the patient and may save some patients from an unrevealing investigation. While a headache due to cerebrovascular disease should be ruled out in patients who appear to have HSA type 2, the extent of the neuroradiological evaluation of stereotypic HSA type 1 depends on the diagnostic confidence of the clinician. Despite the benefit of reassurance, resumption of pleasurable sexual activity may require medication for either long-term prophylaxis, preemptive treatment prior to sexual activity, or acute treatment of the headache. These headaches, like other headaches associated with exertion, may be responsive to indomethacin prior to sexual activity. Frese et al also published their experience with triptans in HSA type 2, showing benefit with either preemptive or acute treatment.2 Clinicians who recognize these benign, but alarming, headaches and offer appropriate treatment will enjoy the gratitude of their patients with HSA.


1. Frese A, et al. Neurology 2003; 61:796-800.

2. Frese A, et al. Cephalalgia 2006; 26:1458-1461.