Acta Neurol Belg DOI 10.1007/s13760-015-0434-z
LETTER TO THE EDITOR
Sexual headache: two familiar orgasmic headache cases and review of the literature A. Vergallo • F. Baldacci • C. Rossi C. Lucchesi • Sara Gori
•
Received: 12 January 2015 / Accepted: 21 January 2015 Ó Belgian Neurological Society 2015
Keywords
Sexual headache Orgasmic headache
Introduction According to the International Classification of Headache Disorders 2013 (ICHD-3), primary headache associated to sexual activity (pSH) is described as a bilateral (in some cases unilateral) occipital or diffuse dull pain headache. Two phenotypes of onset are described: progressive onset with a slow increase during sexual intercourse (also masturbation) worsening at the orgasm or sudden onset immediately before or during the orgasm. pSH last for 1 min to days, often with spontaneous recovery, frequently without any autonomic or vegetative symptoms associated [1, 2]. Some cases are reported with thunderclap headache (TH) onset (described as ‘‘explosive’’) with proximity to orgasm. When SHs first occur, secondary causes should be ruled out. Only one previous report in medline about sexual headaches within a family has been reported [3]. We describe two cases (daughter and mother) of familiar pSH.
Case 1 (daughter) A 28-year-old woman reported a one-year history of headaches always triggered by sexual orgasm especially immediately after and never during sexual intercourse. The sexual activity related headaches consisted of a dull pain, generally bilateral and diffuse but sometimes localized only in the middle of her head, with moderate to severe intensity occurring suddenly during or immediately after orgasm. There was no associated nausea, vomiting or phono/photofobia. The headaches lasted no more than few minutes without taking any medical treatment. She also referred two episodes of TH both occurring during or immediately after orgasm. Her past medical history was unremarkable. She smoked about 20 cigarettes per day. No history of drug or alcohol consumption. Blood pressure, routine blood test and neurological examination were all normal. A brain magnetic resonance imaging (MRI) and intracranial magnetic resonance angiography (MRA) were performed 1 month after her neurology consultation without any pathological findings. In the first episode of TH she underwent brain computed tomography scan and spinal tap, that were both normal.
Case 2 (mother)
A. Vergallo F. Baldacci C. Lucchesi S. Gori (&) Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Pisa, Italy e-mail: [email protected] C. Rossi Neurology Unit, Hospital of Pontedera, Pisa, Italy
This 51-year-old woman referred a post-menopausal (about 4 years) history of headaches described as moderate, dull pain, bilateral fronto-temporal frequently with right prevalence occurring with a sudden increase, shortly following orgasm. No associated symptoms were referred. All headaches lasted from few minutes to 1–2 h. Nonsteroidal anti-inflammatory drugs intake resulted to be completely
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ineffective. She referred a history of menstrual-related migraine since childhood characterized by the presence of a throbbing head pain associated with nausea, light and noise sensitivity lasting few hours up to 2 days. Not other migraine triggers were referred except menstruation. She referred migraine headaches from 4 years menopause occurred. She smoked about 15 cigarettes per day. A remarkable family history of migraine and sexual headache has been reported. The patient reported, indeed, her mother to suffering for a very similar sexual headache. Blood pressure, routine blood tests and neurological examination were all normal. Both MRI brain scan and intracranial MRA proved normal.
Discussion We reported two patients with a history of headache occurring at or shortly after orgasm, which fulfilled the criteria of pSHs as defined by the ICHD-3 (3rd edn; code 4.3.1) in which the pSH was significantly redefined. According to the previous classification (both ICHD I and II) pSH was divided into two subforms consisting in a preorgasmic headache, during sexual activity before orgasm and it seems to be linked to head and neck muscle contraction, and a orgasmic headache, at the height/immediately after orgasm also after masturbation, due to a rapid blood pressure increase. A type 3 described, in the past, as a postorgasmic postural headache resulting from dural tear and intracranial hypotension (identical to the headache occurring after spinal tap). According to the ICHD-3 both preorgasmic and orgasmic are different clinical manifestations of the pSH. According to previous papers, the clinical cases we reported underlines that pSH is a benign headache with no treatment needed, with spontaneous recovery associated to normal neurological examination and not specific pathological signs on brain imaging studies. Some cases of TH occurring during or immediately after orgasm are reported in literature associated to drug (mostly
123
amphetamine) consumption. Reversible cerebral segmental vasoconstriction (RCSV) cases are described in patients with TH onset [4]. This entity is considered of benign nature despite of its clinical spectrum mimicking a subarachnoid hemorrhage. Although the complete pathophysiology of TH and RCSV remains unclear, probably a vasospasm mechanism is involved giving strength to the hypothesis of a vascular pathogenesis of pSH [5]. However, according to our experience and the previous literature, pSH is benign also in the familiar occurrence, nevertheless, following the ICHD-3 recommendations every pSH, at least during its first presentation, should be considered as secondary with special attention to a possible subarachnoid hemorrhage so a diagnostic screening, also in emergency setting, may be mandatory. We hope that further study will be performed to demonstrate the existence of a subgroup of pSH with a familiar and/or genetic pattern. This finding might be clinically useful: if in familiar pSH subgroup patients a negative association with structural brain lesions was, indeed, definitely demonstrated, unuseful and potentially harmful investigations might be consequently avoided. Conflict of interest
None.
References 1. Lance JW (1976) Headaches related to sexual activity. J Neurol Neurosurg Psychiatry 39:1226–1230 2. Evans RW, Pascual J (2000) Orgasmic headaches: clinical features, diagnosis, and management. Headache 40:491–494 3. Johns DR (1986) Benign sexual headache within a family. Arch Neurol 43:1158–1160 4. Evers Stefan, Peikert Andreas, Frese Achim (2009) Sexual headache in young adolescence: a case report. Headache 49: 1234–1235 5. Silbert PL et al (1991) Benign vascular sexual headache and exertional headache: interrelationships and long term prognosis. J Neurol Neurosurg Psychiatry 54:417–421
LETTER TO THE EDITOR
Sexual headache: two familiar orgasmic headache cases and review of the literature A. Vergallo • F. Baldacci • C. Rossi C. Lucchesi • Sara Gori
•
Received: 12 January 2015 / Accepted: 21 January 2015 Ó Belgian Neurological Society 2015
Keywords
Sexual headache Orgasmic headache
Introduction According to the International Classification of Headache Disorders 2013 (ICHD-3), primary headache associated to sexual activity (pSH) is described as a bilateral (in some cases unilateral) occipital or diffuse dull pain headache. Two phenotypes of onset are described: progressive onset with a slow increase during sexual intercourse (also masturbation) worsening at the orgasm or sudden onset immediately before or during the orgasm. pSH last for 1 min to days, often with spontaneous recovery, frequently without any autonomic or vegetative symptoms associated [1, 2]. Some cases are reported with thunderclap headache (TH) onset (described as ‘‘explosive’’) with proximity to orgasm. When SHs first occur, secondary causes should be ruled out. Only one previous report in medline about sexual headaches within a family has been reported [3]. We describe two cases (daughter and mother) of familiar pSH.
Case 1 (daughter) A 28-year-old woman reported a one-year history of headaches always triggered by sexual orgasm especially immediately after and never during sexual intercourse. The sexual activity related headaches consisted of a dull pain, generally bilateral and diffuse but sometimes localized only in the middle of her head, with moderate to severe intensity occurring suddenly during or immediately after orgasm. There was no associated nausea, vomiting or phono/photofobia. The headaches lasted no more than few minutes without taking any medical treatment. She also referred two episodes of TH both occurring during or immediately after orgasm. Her past medical history was unremarkable. She smoked about 20 cigarettes per day. No history of drug or alcohol consumption. Blood pressure, routine blood test and neurological examination were all normal. A brain magnetic resonance imaging (MRI) and intracranial magnetic resonance angiography (MRA) were performed 1 month after her neurology consultation without any pathological findings. In the first episode of TH she underwent brain computed tomography scan and spinal tap, that were both normal.
Case 2 (mother)
A. Vergallo F. Baldacci C. Lucchesi S. Gori (&) Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Pisa, Italy e-mail: [email protected] C. Rossi Neurology Unit, Hospital of Pontedera, Pisa, Italy
This 51-year-old woman referred a post-menopausal (about 4 years) history of headaches described as moderate, dull pain, bilateral fronto-temporal frequently with right prevalence occurring with a sudden increase, shortly following orgasm. No associated symptoms were referred. All headaches lasted from few minutes to 1–2 h. Nonsteroidal anti-inflammatory drugs intake resulted to be completely
123
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ineffective. She referred a history of menstrual-related migraine since childhood characterized by the presence of a throbbing head pain associated with nausea, light and noise sensitivity lasting few hours up to 2 days. Not other migraine triggers were referred except menstruation. She referred migraine headaches from 4 years menopause occurred. She smoked about 15 cigarettes per day. A remarkable family history of migraine and sexual headache has been reported. The patient reported, indeed, her mother to suffering for a very similar sexual headache. Blood pressure, routine blood tests and neurological examination were all normal. Both MRI brain scan and intracranial MRA proved normal.
Discussion We reported two patients with a history of headache occurring at or shortly after orgasm, which fulfilled the criteria of pSHs as defined by the ICHD-3 (3rd edn; code 4.3.1) in which the pSH was significantly redefined. According to the previous classification (both ICHD I and II) pSH was divided into two subforms consisting in a preorgasmic headache, during sexual activity before orgasm and it seems to be linked to head and neck muscle contraction, and a orgasmic headache, at the height/immediately after orgasm also after masturbation, due to a rapid blood pressure increase. A type 3 described, in the past, as a postorgasmic postural headache resulting from dural tear and intracranial hypotension (identical to the headache occurring after spinal tap). According to the ICHD-3 both preorgasmic and orgasmic are different clinical manifestations of the pSH. According to previous papers, the clinical cases we reported underlines that pSH is a benign headache with no treatment needed, with spontaneous recovery associated to normal neurological examination and not specific pathological signs on brain imaging studies. Some cases of TH occurring during or immediately after orgasm are reported in literature associated to drug (mostly
123
amphetamine) consumption. Reversible cerebral segmental vasoconstriction (RCSV) cases are described in patients with TH onset [4]. This entity is considered of benign nature despite of its clinical spectrum mimicking a subarachnoid hemorrhage. Although the complete pathophysiology of TH and RCSV remains unclear, probably a vasospasm mechanism is involved giving strength to the hypothesis of a vascular pathogenesis of pSH [5]. However, according to our experience and the previous literature, pSH is benign also in the familiar occurrence, nevertheless, following the ICHD-3 recommendations every pSH, at least during its first presentation, should be considered as secondary with special attention to a possible subarachnoid hemorrhage so a diagnostic screening, also in emergency setting, may be mandatory. We hope that further study will be performed to demonstrate the existence of a subgroup of pSH with a familiar and/or genetic pattern. This finding might be clinically useful: if in familiar pSH subgroup patients a negative association with structural brain lesions was, indeed, definitely demonstrated, unuseful and potentially harmful investigations might be consequently avoided. Conflict of interest
None.
References 1. Lance JW (1976) Headaches related to sexual activity. J Neurol Neurosurg Psychiatry 39:1226–1230 2. Evans RW, Pascual J (2000) Orgasmic headaches: clinical features, diagnosis, and management. Headache 40:491–494 3. Johns DR (1986) Benign sexual headache within a family. Arch Neurol 43:1158–1160 4. Evers Stefan, Peikert Andreas, Frese Achim (2009) Sexual headache in young adolescence: a case report. Headache 49: 1234–1235 5. Silbert PL et al (1991) Benign vascular sexual headache and exertional headache: interrelationships and long term prognosis. J Neurol Neurosurg Psychiatry 54:417–421
