Abstract
Orgasmic headache (OH) is defined by the IHS as an intense headache with sudden onset at orgasm (1). This uncommon but probably underreported headache is frequently associated with other primary headache disorders including benign exertional headaches (BEH) (2). We present a patient with a history of OH that progressed and converted into several primary headache disorders. Previous reports suggest that patients with orgasmic headaches often suffer from BEH as well (2), and simultaneous onset (3) of both headache disorders as well as onset of OH after a history of BEH have been reported (3, 4). This report describes the inverse sequence and underlines the notion that there may be pathophysiological similarities between OH and other primary headache disorders.
A 33-year-old Caucasian male without significant past medical history and no history of migraine headaches had a 3-year history of severe paroxysmal headaches that were of explosive onset, bioccipital location and exclusively triggered by sexual activity (intercourse or masturbation); he denies vocalizations and also does not feel that he performs a Valsalva manoeuvre during climax, but is not sure about the latter. The patient noticed that these headaches were associated with substantial alcohol consumption during the previous night. He did not bring this to medical attention but presented later for a 3-week history of frequent episodic headaches with identical features, except that these headaches were now triggered not only by sexual activity, but also by straining, holding his breath and moderate physical exertion. The duration of these headaches initially was 30–60 min but decreased to 1–3 min at presentation. In between these headaches, he experienced a continuous dull and mild headache, which was also occipital in location. Magnetic resonance imaging and magnetic resonance angiography of the head were normal. Over-the-counter analgesics and indomethacin in increasing doses up to 75 mg three times daily were of no benefit. About 4 weeks after the initial presentation, the patient noticed improvement of headache intensity and resolution of the continuous headache. At present, he still complains of exertional and orgasmic headaches, but these are less intense and rated tolerable by the patient.
To the knowledge of the authors, this is the first report of the conversion of orgasmic headaches into a co-occurence of exertional, cough and orgasmic headaches, combined for a few weeks with a continuous headache with features of tension-type headache. Frese et al. found that 14 of 40 patients with sexual headaches of the explosive subtype also experienced exertional headaches (2). The fact that identical headaches are triggered by either exertion, cough or sexual activity suggests that there is a common pathophysiological mechanism that is involved in both headache types. Possibly, orgasmic headaches in patients with comorbidity of BEH are manifestations of the same underlying abnormality. An impaired metabolic cerebrovascular autoregulation (5) was described as a causative factor in orgasmic headaches, and vasospasm was seen on angiography in one case report in an individual with concurrent OH and BEH (6). In this case report, the patient's observation that his OH are associated with alcohol binges may be related to impaired vasoreactivity induced by alcohol, since higher doses impair endothelium-dependent vascular relaxation responses (7), but this remains speculative at this point, especially since there are no other reports of a correlation of OH with alcohol. Independent of this, sudden increase of intrathoracic pressure as seen with the Valsalva maneuver was felt to be the trigger factor for both orgasmic and cough headaches (8), but it is doubtful whether a Valsalva maneuver is performed by this and other patients with OH. In any case, the reason why there is only partial overlap between orgasmic and BEH remains elusive. A comparison between patients with orgasmic headaches with and without comorbidity of exertional headaches may be helpful.