Headache (benign coital)

Coital cephalgia is a headache related to sexual activity usually at or near orgasm (1):

• there may be one episode or several with no defined periodicity
• there is usually a short course, but occasionally it can have a duration of years
• usually no identifiable underlying cause
• may be associated with migraine or tension headache
• incidence is higher in men than women

The classical orgasmic headache is typically severe, throbbing, or explosive in nature, beginning at the moment of orgasm or shortly thereafter

• this particular type of headache could be classified within the group of thunderclap headache (TCH)

The first time a patient experiences post-coital cephalgia the differential diagnosis includes subarachnoid haemorrhage (SAH)

• differential diagnosis with the sentinel headache observed during the development of an aneurysmal rupture is extremely important
  • this intense, sudden type of headache occurs in 30% to 60% of patients days or weeks before rupture of the aneurysm, which seems to result from partial rupture with leakage of blood
  • in about 50% of patients, this "warning sign" is abrupt in onset and may be very intense
  • all patients with TCH should be investigated with at least a CT scan and MR angiography, since this type of headache is not a frequent benign recurrent headache disorder, and may represent a serious underlying process

As a pattern to the headaches becomes apparent the diagnosis becomes clear.

A NSAID e.g. indomethacin, may be used as analgesia if not contraindicated.

Notes:

• the pathophysiology of TCH in the absence of underlying pathology is not well understood
  • primary TCH has a distinctive clinical and angiographic profile and must be distinguished from central nervous system vasculitis and SAH

Reference:

1. Lin PT, Chen SP, Wang SJ. Update on primary headache associated with sexual activity and primary thunderclap headache. Cephalalgia. 2023;43(3):3331024221148657.