Abstract
Primary headache associated with sexual activity appears to be relatively uncommon in a clinic-based study in Indian patients. Only 24 patients (M : F 18 : 6) were encountered over a 20-year period (1985–2004). Of the 18 male patients, 14 (age 33–42 years) had preorgasmic headache of tension-headache type for 2–8 months, one patient (age 58 years) had orgasmic headache of vascular type for 1 month and three subjects (age 19–23 years) had masturbatory headache also simulating tension-type headache for 3–7 weeks. These observations are at variance with those generally reported from western countries. Of the six female patients, four (age 26–32 years) had typical orgasmic headache of the vascular type (for a few months to a few years), only one of whom had been a migraine sufferer. One patient (age 35 years) presented with a single episode of thunderclap headache where angiography had been negative. Another female subject (age 30 years) experienced typical orgasmic headache only during masturbation but not during actual sexual intercourse. Occurrence of sexual headaches in both male and female subjects had been unpredictable. Few had associated migraine and none ever experienced exertional headache.
Introduction
The International Headache Society (IHS) in its recent (2004) classification (1) and diagnostic criteria of headache disorders recognizes primary headache associated with sexual activity as a distinct form of primary headache disorder and prefers this terminology to previously used ones such as benign sex headache, coital cephalgia, benign vascular sexual headache and sexual headache. The association of headache with ‘immoderate venery’ (excessive sexual activity) has of course been known since the time of Hippocrates (2, 3). In modern times, the first clear description of benign sexual headache (BSH) was made by Kriz in 1970 (4) and was soon followed by two brief reports by Martin (5) and Lance (6). It was of course Lance (3) who probably made the first detailed study of 21 patients and later wrote an editorial on the subject in the British Medical Journal (7). Lance (3) and Paulson (8) recognized three different forms of BSH : Type 1 (a muscle contraction type of headache in the preorgasmic phase), Type 2 (a bursting vascular type of headache at height of orgasm) and Type 3 (a post-orgasmic postural headache due to CSF leak from dural tear). The IHS in 2004 (1) made some modification to this classification system. Type 1 BSH has been designated as preorgasmic headache (4.4.1) and Type 2 as orgasmic headache (4.4.2). Thunderclap headache is coded separately (4.6) but its association with sexual activity is clearly indicated when it should be coded as 4.4.2.
Sexual headache (precipitated by coitus or even masturbation) undoubtedly remains underdiagnosed and under-reported because of the reluctance on the part of sufferers to volunteer such information. This is all the more important in Indian society where significant social taboo prevents scientific studies on sexuality and medical disorders related to sexual activity. The purpose of the present communication is to appraise readers of the pattern of BSH seen in a clinic-based Indian neurological practice (not a population-based study) and of certain variations observed in Indian patients, some of which may be linked to socio-cultural differences.
Materials and methods
Between 1985 and 2004, a total of 24 patients presented to the author's clinic (general neurology clinic) with two or more headache spells (except in one case) which were thought to be primary headaches associated with sexual activity or BSH. These cases fulfilled the diagnostic criteria of primary headaches associated with sexual activity as defined by the IHS (1) on retrospective analysis of case notes. There were 18 males and six females. A detailed clinical history (including sexual behaviour during headache spells) was obtained and recorded. Thorough neurological examination and neuroimaging studies [contrast computed tomography (CT)/magnetic resonance imaging (MRI) of the brain] were preformed in all cases. CSF study and formal cerebral angiography were performed in only one case (discussed below). In three male patients where diagnosis of BSH was originally made, contrast MRI (and later CT/MR angiography) revealed the presence of unruptured cerebral aneurysms and these cases were excluded, though no definite cause–effect relationship could be established in any (basically to fulfill the diagnostic criteria). Patients with ongoing migraine or tension-type headache, made worse during sexual activity, were also excluded. Of these 24 patients, most were lost to the clinic once they had been reassured. Only 12 patients could be followed up, including one woman and a male patient who remain under follow-up for several years for associated epileptic seizures and other neurological problems, respectively.
Results
In the present communication, headaches associated with sexual activity in men and women are described separately. Also discussed separately are headaches related to sexual intercourse and those related only to masturbation. However, no clear distinction probably exists between the two and, though discussing these separately might appear arbitrary, it has been done to highlight some phenomenological and situational differences between the two groups and some cases may have a psychic basis related to cultural norms in the country.
Primary headaches associated with sexual activity in men
Headaches related to sexual intercourse
During the study period 15 male patients [14 patients in the age group 33–42 years (mean 37.7 years, SD 2.3); one subject aged 58 years] presented with a least two headache spells during coitus with their usual partners. All patients had been married for ≥10 years at the time of first experiencing the coital cephalalgia. At the time of presentation, three patients were diagnosed to have hypertension and were under treatment (atenolol one case and amlodipine two cases) and one patient (age 58 years) had both hypertension (on amlodipine) and Type 2 diabetes. Only two patients had experienced migraine-like headache (without aura) in the past. The relatively younger 14 patients had been experiencing coital cephalalgia for 2–8 months prior to presentation (mean age at onset roughly the same as age at presentation). The relatively elderly patient aged 58 years had experienced two spells of coital cephalalgia in the month preceding first presentation. The number of such headaches experienced by the 14 patients at presentation varied from five to over 30 (exact numbers not available in all patients).
Fouteen patients presented with pre-orgasmic headache with tightness felt over the neck, spreading upward and then forward and then developing a dull pressing headache holocranially, increasing in intensity with mounting sexual excitement. None had any jaw tightness/pain, any vascular element in the headache phenomenology and none complained of any nausea during the headache spells. In all these 14 patients, the headache subsided within 30–45 min of completion of the sexual act. The total duration of the headache from onset to disappearance varied from 45 to 75 min. The duration varied in the same individual from day to day; however, the mean duration of the total headache spell appeared to be around 50 min.
Only one patient aged 58 years (a doctor) presented with two spells of holocranial bursting headache (orgasmic headache; Type 2 BSH) at orgasm for the first time in his life. This suddenly started 3–4 min before ejaculation and lasted for about 30 min after completion of the sexual act with diminishing severity.This was not associated with any nausea or vomiting but caused considerable discomfort and anxiety. Self-checking of blood pressure (BP) revealed only a modest (15–20 mmHg) rise in systolic blood pressure (SBP) soon after completion of the sexual act while the headache persisted. In view of his age and vascular risk factors, he was thoroughly investigated with contrast-enhanced MR brain and angiograhpy but no significant pathology could be detected. A course of indomethacin 100 mg daily had not been of much help and he experienced a few (about six) such vascular headache spells over the next couple of years but not during every sexual act. β-Blockers were not tried because of his diabetes. Recently he had been re-examined for a possible syncopal attack when he mentioned that, though sexual activity had of late become rather infrequent, the bursting headache spells have stopped recurring.
Of the 14 patients with pre-orgasmic headache, eight returned for follow-up at 3 months. All had experienced more than one pre-orgasmic headache during the intervening period (again not on every occasion) and were reassured. None of the patients with such pre-orgasmic headaches were put on any medication (including β-blockers) regularly other than a combination of paracetamol and a muscle relaxant when needed, which helped in most instances.
Headache related to masturbation
Only three subjects (aged 19, 22 and 23 years) presented with headache related to masturbation. All subjects were unmarried and had no actual sexual experience. Although masturbatory habits in all had been fairly regular (three to six times/week), headaches occurred during most such spells but not all for 3–7 weeks prior to presentation. Mild to moderate holocranial dull headache (feeling of tightness/heaviness) were felt by all (not starting in the cervical region) immediately prior to ejaculation and lasted with declining severity for the next 15–20 min. The headaches had never been throbbing, bursting or explosive and never associated with any nausea or vomiting. None returned for follow-up after initial examination, investigation and reassurance.
Primary headaches associated with sexual activity in women
A total of six female subjects with BSH were encountered during the study period. For ease and clarity of descriptions of their headache phenomenology, they have been described individually as cases A–F. The cases are not described chronologically as they were encountered.
Headaches related to sexual intercourse in women
Case A, B, C
Aged 28, 30 and 26 years, respectively, they had all been married for more than 5 years. All three presented with recent (1–2 months) onset of throbbing cervico-occipital headache spreading bitemporally, occurring only during sexual intercourse. The headache commonly started only a few minutes prior to achieving orgasm, when it reached its cresendo (bursting) and subsiding in 30–60 min or on going to sleep, whichever had been earlier. In none of the three cases had the headache occurred during every instance of sexual intercourse and have any relation to physical fatigue or psychological strain or tension. These had not been associated with any nausea or vomiting and none had any history of migraine or any form of exertional headache. Only one case (case B) had a family history of migraine. Clinical examination and investigations, including neuroimaging, had been negative in all three patients.
Case D
This 32-year-old lady, married for over 7 years, generally spends little time (approximately 2 months/year) with her husband, who is away as a ship's captain. For the past 3–4 years before presentation, on most (not all) occasions of sexual encounter with her husband, she had experienced bursting holocranial headache of moderate to severe intensity at the time of orgasm lasting 30–45 min and unassociated with any nausea. She had had a number of attacks of migraine without aura since her mid 20s but described the nature of the sexual headaches to be very different: more severe, bursting rather than throbbing, holocranial always rather than hemicranial and no nausea. Clinical examination and neuroimaging studies had been negative. She received partial benefit from taking indomethacin 50 mg approximately 1 h before an anticipated sexual encounter.
Case E
This 35-year-old lady, married for more than 10 years, presented one evening with acute onset of severe explosive headache with one bout of vomiting which developed in the same afternoon while taking a shower. Though found normotensive and having no meningeal signs, she was admitted with a provisional diagnosis of subarachnoid heamorrhage. CT Scan and CSF study done within 24 h were negative and the headache settled down with analgesic and tranquilizers in about 12 h. Digital subtraction angiography (DSA) cerebral angiography to exclude an unruptured aneurysm a week later was also negative. She was diagnosed to have had a ‘thunderclap headache’ but the cause was not apparent. Later on, on closer questioning, she admitted having had a ‘particularly passionate’ sexual act with her husband in the shower and developed the sudden explosive headache at the height of the orgasm.
Headache related to masturbation in women
Case F
A 24-year-old lady was first seen and investigated in 1986 for epileptic seizures which were controlled with phenytoin 300 mg daily. She was married and leading a perfectly normal sex life with her spouse and had never had any significant headache-related problem. She experienced some marital problems in 1992, and started living separately. It was at that time that she started practising masturbation on a very regular basis, during many of which she could achieve satisfying orgasm. On many (not all) such occasions at the height of orgasm, she developed bitemporal throbbing, at times occipital and at times holocranial bursting headaches not associated with nausea. These lasted for around 30–40 min at the most. She had not been a migraine sufferer. Prophylactic therapy with indomethacin (100 mg daily) offered partial relief but had to be discontinued due to gastric problems. Propranolol exacerbated her pre-existing asthma. In 1999, she got remarried and started a ‘normal’ sexual life with her second husband and rarely practised masturbation. The headaches almost completely disappeared, occurring only very occasionally while masturbating, but never while having a coitus.
Discussion
From the observations made in the present study it may appear that primary headaches related to sexual activity are relatively uncommon in Indian patients. Only 24 patients have been encountered over a 20-year period, whereas on average nearly 1000 ‘new’ patients with various forms of primary headache are seen in the author's clinic every year. However, any conclusion should be drawn rather cautiously. First, the present study is not population based. Second, the overall attitude of Indian people towards all matters relating to sex are very conservative and most are extremely shy of discussing sex-related problems. It is highly likely, therefore, that many such sex-related problems (e.g. headache) remain unrecognized and under-reported.
Frese et al. (9) commented on a high comorbidity of BSH with migraine (25%), benign exertional headache (20%) and tension-type headache (45%). Observations in the present series of Indian patients have been at variance with these findings and only in occasional patients has the co-existance of migraine but not exertional headaches been observed. Furthermore, in the aforementioned study as well as in other studies from the west, Type 2 BSH far outnumbered Type 1 BSH cases in males—a reverse of the observation made in the present study. Clearly such differences are likely to be at least partly artefactual, as these observations are based on a relatively small number of patients and population-based studies are yet to be performed.
The mean age of onset of coital cephalalgia in the study by Frease et al. (9) had been 39.2 years, which is not much different from that recorded in male patients with Type 1 BSH in the present series (37.7 years). However, these workers noted two distinct peaks in relation to age of onset: an early peak between years 20 and 24 and a rather late peak between years 35 and 44. In the present series the early age onset group was not apparent. While there is no clear explanation for this difference, it may perhaps be related to a generally higher age at marriage of urban-educated Indian men. As an analogy, it may be noted that the three male subjects (all unmarried) in the present series with masturbatory Type 1 BSH had been much younger (19–23 years).
Judging by the headache phenomenology as detailed above, it seems easier to discuss BSH in men and women separately, as their individual roles in the sex act may be somewhat different. Of the 15 male subjects with coital headache, 14 experienced pre-orgasmic headache (BSH Type 1) and only one, a relatively elderly man, had typical orgasmic headache (BSH Type 2). This is surprising considering the fact that most previous studies concentrated more on the orgasmic headache, presumably of vascular origin, and often discussed it with other similar conditions such as exertional headache (10–13) (mentioned above). Also intriguing has been the observation that such headaches started occurring a number of years after starting an active sexual life and then, too, not on every occasion. Whether the latter may be related to degree of physical exertion (or passion) remains undetermined.
The rationale for describing cases of masturbatory headaches separately needs some comment. The available literature does not hint at any phenomenological difference between headaches associated with masturbation and those associated with actual sexual intercourse. Patients indeed may experience both forms of headaches at different times. The three young men with masturbatory headaches in the present series experienced sudden-onset, short-lasting pre-ejaculatory headaches associated with orgasmic experience. The headaches were of the tension type. While the pathogenesis of tension-type headache in general is not always clear (and that includes the pre-orgasmic variety of BSH), psychic factors related to cultural norms may be of some importance in these three young men. In Indian society young people often feel guilt regarding the practice of masturbation, considering it as some form of sexual perversion and a sinful act. It is possible such factors may be implicated in the genesis of masturbatory orgasmic tension-type headaches as noted in the present series.
Case F, a female subject, who experienced vascular type orgasmic headache only during masturbation but never during actual sexual intercourse, is intriguing. This phenomenological difference and the underlying pathology remain unexplained.
The female patients included in the series have been discussed as individual cases with brief clinical notes, primarily to highlight the uniqueness in their clinical presentation. Cases A, B and C presented with fairly typical features of orgasmic cephalalgia (Type 2 BSH). However, the question remains, why did these start a number of years after experiencing an active sexual life and never experiencing any form of exertional headache? Clearly such factors need consideration in discussing the pathogenic mechanisms involved. Case D had a similar clinical presentation but has been discussed separately only because she had been a regular migraine sufferer and her orgasmic cephalalgia had been very different from her usual migraine headaches. But again, in this case also, the orgasmic headaches appearned some years after her marriage. This phenomenon of delayed occurrence had also been the present author's experience with male patients presenting with both pre-orgasmic (Type 1 BSH) and orgasmic headache (Type 2 BSH) (see acove). The unpredictable nature of the occurrence of sexual headaches and not being precipitated by every sexual act has also been commented on previously (13).
Case E had a primary thunderclap headache associated with sexual activity and angiography had been negative. The association of thunderclap headache with sexual activity headache or even unruptured aneurysms has been well documented. In 1986, Day and Raskin (14) described thunderclap headache as a sudden and intense generalized headache, similar to the pain described by patients during an aneurysmal rupture, but with a bloodless CT and CSF examination. These were associated with unruptured cerebral aneurysms. Previously, Fisher (15) defined such a subtype of headache as ‘crash migraine’. Slivka and Philbrook (16) reported on four patients (three women and one man) with thunderclap headache and diffuse segmental cerebral arterial vasoconstriction, with no aneuysmal formation or subarachnoid haemorrhage. However, some of these patients had neurological signs, presumably related to the vasospasm. Dodick et al. (17) more recently highlighted the occurrence of segmental cerebral arterial spasm in two patients with thunderclap headache, one developing it after sexual intercourse. Similar cases have also been described by others (18, 19). In the present author's case (case E), no significant arterial spasm could be detected on angiography, perhaps because the procedure was performed rather late. In a recent prospective study by Landtblom et al. (20) of sudden onset headaches (thunderclap headache) of various pathologies, 8% of subjects had thunderclap headache during sexual activity and two patients had subarachnoid haemorrhage. These authors of course did not justify performing angiographic studies in thunderclap headache patients with negative CT and CSF examination.
The pathogenesis of primary headache associated with sexual activity remains largely unexplored. Years ago, Lance (3) raised the possibility of muscle contraction (selectively in neck and cranial muscles) in the genesis of pre-orgasmic cephalgia (Type 1 BSH) and some subjects with Type 1 BSH were prone to tension-type headache also. Patients at times can reduce the intensity of pre-orgasmic headache by adopting relaxation methods while continuing sexual activity. Also, some may experience similar headache even while playing only a passive role but feeling tension building up in the forehead, jaw and neck muscle (3). While the analogy with tension-type headache may appear simple, not all tension-type headaches are associated with increased contraction of pericranial muscles, and this has not been documented to occur, either, in patients with pre-orgasmic cephalalgia of the dull pressing type.
It is tempting to hypothesize that cephalalgia (BSH Type 2) of vascular (throbbing/bursting) nature is related to the haemodynamic alterations which occur at the height of orgasm. The SBP may go up by 40–100 mmHg and the diastolic by 20–50 mmHg, accompanied by a significant rise in heart rate (21). This simple explanation also appears incomplete. A significant rise of BP and heart rate occurs in many individuals during several forms of activity in daily life. but they rarely produce headaches. Some individuals who develop benign exertional headache (which has been closely linked to BSH) usually experience these at times of performing strenuous work involving an increase in intrathoracic pressure which may cause a transient increase in intracranial pressure and headache. In some others, however, the headache may be related to a transient rise of BP and heart rate. Based on transcranial Doppler studies, such headaches may result from impaired autoregulation of cerebrovascular smooth muscle. This dysregulation in susceptible individuals may render resistance vessels unable to respond adequately to increased blood pressure during exercise, resulting in abnormal vasodilation, vessel wall oedema or increased blood volume (22). A similar phenomenon may occur in subjects prone to benign orgasmic cephalalgia. The coexistence of exertional headache and orgasmic cephalalgia is well documented and such headaches may occur close to each other, suggesting a ‘priming of vessels’ by one type of headache for the other (12). On the other hand, although an increase in BP is universal during sexual activity, a recent study has shown that patients with sexual headache experience a significantly greater increase of BP during standardized physical exercise compared with healthy subjects and migraine patients (23). This observation raises the question of altered central autonomic control of BP in these individuals. Clinical observations in the present series raise few unsolved issues—the onset of sexual headaches (both Type 1 and Type 2) have been delayed in most (several years after marriage), they did not occur during every sexual encounter, and in one male patient with Type 2 BSH only a modest rise of BP was recorded immediately afterwards.