Abstract
Orgasmic headache (headache associated with sexual activity type 2 according to the International Headache Society classification) is a sudden severe headache which occurs at orgasm. Experiences with triptan therapy are described. Two out of four patients with severe headache continuing for >2 h had a positive response to acute triptan therapy. Two out of three patients using triptans as short-term prophylaxis reported a reliable response on several occasions. Trip- tans might be a treatment option to shorten orgasmic headache attacks after the diagnosis is clear and, particularly, subarachnoid haemorrhage has been excluded. In patients who chose to predict their sexual activity, short-term prophylaxis with oral triptans 30 min before sexual activity might be a therapeutic option in those not responsive to or not tolerating indomethacin.
Keywords
Introduction
Since the first systematic descriptions in 1974 and 1976 (1, 2), primary headache associated with sexual activity (HSA) has become a well defined entity (3). The exact prevalence of HSA is unknown. In the only population-based epidemiological study, the lifetime prevalence was about 1% with a broad confidence interval and similar to that of benign cough headache and benign exertional headache (4). It is likely that the prevalence of this headache is underestimated, since patients often feel embarrassed to report intimate details about their sexual activities. We estimate that patients with HSA account for aproximately 1% of all headache patients in our supraregional headache clinics.
The second edition of the International Headache Society (IHS) classification differentiates two types of HSA (5). Type 1 is a dull ache in the head and neck associated with the awareness of neck and/or jaw muscle contraction which increases with sexual excitement. It is also called preorgasmic headache. Type 2, so-called orgasmic headache, is a sudden severe (‘explosive’) headache which occurs at orgasm. At the first presentation of orgasmic headache, it is mandatory to exclude symptomatic headache such as subarachnoid haemorrhage (5). Orgasmic headache can be frightening, distressing and disabling. Fortunately, the prognosis is good and in the majority of patients the headache disappears without any specific treatment (6). Nevertheless, acute or prophylactic treatment can be necessary in patients with severe acute pain or with repeated attacks. We describe our experiences with triptans in the treatment of orgasmic headache.
Cases
Demographic data, pain character and localization and comorbidity with other primary headaches are summarized in Table 1. All patients fulfilled IHS diagnostic criteria for orgasmic headache with a very severe explosive headache starting at orgasm with an intensity of 8–10/10 on a visual analogue scale (VAS). In all patients, symptomatic headache had been excluded by computed cerebral tomography and lumbar puncture.
Demographic data, pain character and localization, and comorbidity with other primary headaches in patients with orgasmic headache
Patient 1
A severe pain started exactly at orgasm and lasted for 6 h with an intensity of 9/10–10/10 on a VAS. There were no accompanying symptoms and no response to acetylsalicylic acid (ASA) 500 mg. The next day, a very similar headache (VAS 8/10) occurred during masturbation lasting for 6 h with no response to paracetamol 500 mg. The next day, he attended our Emergency Department after a third attack during sexual intercourse. He was treated with sumatriptan 6 mg s.c. 3 h after the onset of pain. The pain decreased 30 min later from 8/10 to 5/10 and stopped 4 h after onset. Two and 4 days after discharge he had two further attacks during sexual intercourse which he immediately treated with intranasal zolmitriptan 5 mg. Both times, the pain decreased from 8/10 to 3/10 45 min after intake and stopped after 90 min. For a follow-up period of 22 months no further attacks occurred without prophylactic treatment.
Patient 2
The patient had suffered from migraine without aura for 30 years and from orgasmic headache for 10 years. Her migraine frequency was two to three attacks per month with a duration of 24–48 h each. Orgasmic headache occurred irregularly on about 50% of occasions with sexual intercourse without longer remissions. It regularly lasted 3–4 h without treatment. She could clearly distinguish orgasmic headache from migraine by its different character. Encouraged by her positive experience with different triptans in migraine, she started treating her orgasmic headache with almotriptan. When first presenting to our out-patient clinic, she had treated 20–30 attacks of orgasmic headache with almotriptan 12.5 mg and had become pain free 30 min after intake. Intermittent untreated attacks had an unchanged duration of 3–4 h. We started prophylactic treatment with propranolol 40 mg b.d. with a complete remission of HSA for a follow-up period of 6 months.
Patient 3
The patient attended our Emergency Department 1 h after the first occurrence of an orgasmic headache. Despite treatment with intranasal zolmitriptan 5 mg, the severe pain lasted for 12 h. Treatment of a second attack with zolmitriptan 5 mg was without success. Prophylactic treatment with indomethacin 50 mg 30–60 min before sexual activity prevented further attacks on two occasions but was not tolerated because of abdominal discomfort. After a third attack during masturbation, treatment with metoprolol 50 mg caused complete remission for 3 months. It was tapered off without further attacks for a follow-up period of 2 years.
Patient 4
The patient attended our Emergency Department 90 min after the first occurrence of an orgasmic headache. He was treated with sumatriptan 6 mg s.c. 3 h after onset. Nevertheless, the severe pain lasted for 12 h. No further attacks occurred for a follow-up period of 3 years.
Patient 5
The patient had a history of migraine without aura from puberty prophylactically treated with verapamile (480 mg/day) and amitriptyline (100 mg at night). She had suffered from severe orgasmic headache during nearly every sexual activity for 5 years. The pain regularly lasted for 6–12 h and was accompanied by nausea. This frightened her so much that she tended to curtail her sexual activities to some extent. She had once tried a tablet of sumatriptan 50 mg half an hour before sexual intercourse and was surprised when the headache failed to appear. Ever since she has used this short-lasting prophylactic treatment with a reported efficacy of 100%.
Patient 6
The patient had suffered from migraine without aura for 25 years and from orgasmic headache with 50% of sexual activities for 5 months. When first presenting to our out-patient clinic she had suffered from 10 orgasmic headaches, very severe ones (10/10) lasting for 5–10 min and more moderate ones (4–5/10) for 3–5 h. Prophylactic and acute intake of metamizole had been unsuccessful. We recommended prophylactic use of naratriptan 2.5 mg 30–60 min before sexual activity, which did not prevent four further attacks. Intake of indomethacin 50 mg 30–60 min before sexual activity decreased attack severity and duration by 50%. Combination therapy with indomethacin 50 mg b.d. and propranolol 40 mg b.d. brought complete remission of orgasmic headache for a follow-up period of 2 years with a recurrence during a drug holiday after 18 months.
Patient 7
This patient had no history of headache. When first presenting to our out-patient clinic, he had suffered from four orgasmic headaches and one exertional headache during the last week, being severe for 15 min and moderate for several hours. We recommended prophylactic use of indomethacin 50 mg 30–60 min before sexual activity, which did not prevent two further attacks. Intake of rizatriptan 10 mg 30 min before sexual activity prevented three further attacks. Without treatment, orgasmic headache reappeared on two following occasions. Afterwards, prophylactic intake of almotriptan 12.5 mg 45 min before sexual activity prevented two further attacks. Without treatment, no further attacks occurred for a follow-up period of 3 months.
Discussion
Triptans are an effective and well-tolerated treatment for acute migraine and cluster headache. Additionally, they may have short-term prophylactic properties in chronic migraine, menstrual migraine and cluster headache (7–9), although not without risk of medication overuse. For HSA, there has been a single report of succesful short-term prophylaxis with naratriptan in a 54-year-old woman suffering from orgasmic headache (10). Because of its relative rarity, management of HSA is based on experience and case series, not on any randomized trials.
For acute treatment, analgesics (ibuprofen, diclofenac, paracetamol, ASA) given after the onset of headache are of limited or no value in nearly all patients (6). Severe pain continues for >2 h (up to 24 h) in approximately 25% of patients with HSA (11). For these patients, triptans might be a treatment option to shorten the attack. Based on our limited experience, the response rate for triptans in the acute treatment of orgasmic headache is approximately 50%. In the majority of patients, HSA appears in a bout of some weeks or months and disappears without any specific treatment (12, 13). The number of attacks within one bout ranges from 2 to 50 (11). Sometimes a bout recurs. About one-quarter of patients suffer from continued attacks without longer remissions. For patients with longer lasting bouts, or with continued attacks, long-term prophylactic treatment with propranolol can be successful (6, 14, 15). Alternatively, in patients who chose to predict their sexual activity, short-term prophylaxis with indomethacin can be tried. Indomethacin in an oral dose between 25 and 100 mg given 30–60 min prior to sexual activity has been successful in several patients, whereas ibuprofen and diclofenac have not (6, 13, 14). Empirically, response rates for both propranolol and indomethacin are approximately 80%. However, continuous intake of propranolol is not adequate in those with only sporadic sexual activity. Indomethacin can cause serious gastrointestinal side-effects and is not tolerated by at least 10% of headache patients (16). Based on our experience with patients 5 and 7, short-term prophylaxis with oral triptans 30–45 min before sexual intercourse might be a therapeutic option in those not responsive to or not tolerating indomethacin. This mirrors older experience that short-term use of the ergotamine inhaler, when available, was often useful in the same settings (Goadsby, unpublished observations).
Triptans are highly selective agonists at the serotonin, 5-hydroxytryptamine, 5-HT1B/1D receptor. The exact mechanism of how triptans relieve headache is still unknown. In migraine, selective cerebral vasoconstriction, inhibition of trigeminal neuropeptide release and inhibition of the trigeminal nucleus caudalis seem to be the most important pharmacological mechanisms (17). The exact pathophysiology of HSA is unknown. Several authors have emphasized a pathophysiological relationship between orgasmic headache and migraine (13, 18) and postulated a release of vasoactive substances such as neurokinins, serotonin and catecholamines (1, 13). This hypothesis is supported by the fact that patients with orgasmic headache have a similar loss of cognitive habituation as patients with migraine (11). During visual event-related potential testing, both are characterized by potentiation instead of habituation of stimulation-evoked cortical responses. Furthermore, comorbidity of migraine, or of a family history for migraine, with orgasmic headache has been shown in several case series (3, 13, 14, 18). The partial response of orgasmic headache to triptan therapy indirectly supports a pathophysiological similarity to migraine. Nonetheless, any definite link between orgasmic headache and migraine still remains to be determined. It is essential to emphasize that triptan therapy in orgasmic headache can be considered only after the diagnosis is clear and, particularly, subarachnoid haemorrhage has been excluded by appropriate investigation. Until a controlled study confirms our positive experiences, triptan therapy can be recommended as second-line treatment merely in those not responsive to or not tolerating standard treatment.