Sexual activity associated headache is uncommon problem affect some people
He we done presentation on this medical illness we take this problem from all sides
Introduction
PATHOPHYSIOLOGY
Epidemiology
Evaluation and diagnosis
DD
and eventually treatment
2. INTRODUCTION
Headache associated with sexual
activity is one of the uncommon
headache syndromes that occurs in
t h e s e t t i n g o f a s p e c i f i c
triggers.onset may be gradual
during sexual activity or sudden at
t h e t i m e o f o r g a s m .
3. Other term
Sexual headache
Benign vascular sexual headache
Coital/intercourse
cephalalgia/Headache
Pre-orgasmic or orgasmic
cephalalgia/Headache
4. PATHOPHYSIOLOGY
The causes of are unknown, and the proposed
mechanisms are largely speculative. are difficult
to study because of their relative rarity and
variable pre-orgasmic and orgasmic clinical
presentations. Pre-orgasmic headaches have :
proposed to arise from excessive contraction of
neck and jaw muscles during sexual activity and
might be avoided by conscious relaxation of these
muscles during intercourse .
5. Follow:PATHOPHYSIOLOGY
Orgasmic headaches : attributed to rapid
increases in blood pressure and heart rate that
occur during orgasm . Trigeminovascular
activation may cause vasodilation due to release
of inflammatory neuropeptides, leading to
cerebrovascular dysregulation and head pain,
similar to proposed mechanisms in migraine [
6. Epidemiology
Primary headache associated with sexual activity
is rare, but its exact prevalence and incidence is
unknown. The male to female ratio approximately
3:1 The mean age of onset is 37 to 39 years but
can present at any sexually active age .Other
primary headache syndromes are common in
patients with sexual headache, migraine (25
percent), exertional headache (29 percent), and
tension-type headache (45 percent).
7. Clinical features
The onset of headache with sexual
activity characterizes the syndrome.
Symptoms may occur with sexual
intercourse or masturbation and may
recur with subsequent sexual activity .
8. - Head pain
bilateral in approximately two-thirds of patients
and unilateral in one-third . typically occipital or
diffuse. . pressure-like or throbbing and can vary
in peak intensity from mild to severe. .Severe
symptoms are often brief, lasting several minutes
in most patients, but a milder headache may
persist for 24 up to 72 hours.
9. Clinical variability
has traditionally been divided into two
types, pre-orgasmic and orgasmic, each
with somewhat distinct clinical features:
10. Pre-orgasmic headache
This "dull type" typically features pressure-like or aching pain
.that appears during sexual activity and gradually increases with
mounting sexual excitement
. Patients may note increased contraction in neck and jaw muscles
along with the headache.
Symptoms are often very brief. persisted for about 30 minutes on
average with a range from 1 to 180 minutes.
30% of the primary headaches associated with sexual activity .
11. Orgasmic headache
"explosive type," characterized by a sudden onset of severe head pain
occurs just prior to or at the moment of orgasm and followed by
severe throbbing head pain.
may generalize rapidly to involve the entire head.
The severe pain often lasts for <15 minutes, but the subsequent
throbbing head pain often persists for several hours .
70 percent of primary headache associated with sexual activity .
Note:Sexual headaches may be unpredictable and are not necessarily
precipitated with every sexual encounter .
12. Associated symptoms
Severe headaches associated with sexual activity may be
associated with nausea and vomiting..Cranial autonomic
symptoms do not typically occur with the headache.
13. Evaluation and diagnosis
. suspected when characteristic headache symptoms occur
during sexual activity.
. requires the exclusion of subarachnoid hemorrhage (SAH)
and other secondary causes.
14. Diagnostic criteria
The diagnostic criteria from the International Classification of
Headache Disorders, 3rd edition (ICHD-3) are as follows :
(A) At least two episodes of pain in the head and/or neck fulfilling all
the criteria below
(B) Brought on by and occurring only during sexual activity ●
(C) Either or both of the following:Increasing in intensity with
increasing sexual excitementAbrupt explosive intensity just before or
with orgasm
(D) Lasting from 1 minute to 24 hours with severe intensity and/or up
to 72 hours with mild intensity
(E) Not better accounted for by another ICHD-3 diagnosis
15. Probable diagnoses
there is only one episode fulfilling criteria B
through D or if there are at least two headaches
fulfilling criterion B and either (but not both) of
criteria C and D
16. Approach
Patients reporting sudden-onset severe symptoms,
including those with orgasmic onset of symptoms, should
be evaluated urgently SAH and other acute conditions that
may present with thunderclap headache .
Once urgent evaluation excludes SAH, further evaluation
to exclude other secondary causes is warranted for
patients with orgasmic headache symptoms and for all
patients with new-onset pre-orgasmic headache
symptoms.
17. Evaluation for subarachnoid hemorrhage for
patients with orgasmic headache symptoms —
Orgasmic headache is particularly worrisome because of its similarity
to theheadache of SAH, and because 4 to 12 percent of patients
presenting with SAH due to an aneurysmal rupture cite sexual
intercourse as the precipitating event.
The workup to exclude SAH typically includes:
Head computed tomography (CT) to identify acute bleeding
Lumbar puncture (LP) to identify xanthochromia in cerebrospinal fluid
(CSF)
Additional testing if initial testing is nondiagnostic (eg, blood in CSF
attributed to traumatic LP) or delayed (eg, >2 weeks from symptom
onset). After SAH has been excluded, if initial testing has not
identified an alternative structural cause to symptoms, further testing
to exclude other structural causes is warranted.
18. Evaluation for other secondary causes
for all patients
For patients with orgasmic headache symptoms not
attributed to SAH and for patients presenting with new-
onset preorgasmic, dull headache symptoms, we suggest
evaluation to exclude secondary causes.
Patients who present pre-orgasmic headache symptoms, a
chronic history of multiple similar prior episodes
consistent with primary headache associated with sexual
activity, and a normal examination may not require
additional diagnostic evaluation.
20. Testing to exclude secondary causes
CT- or MR-angiogram of head and neck
MRI brain and MR venogram with gadolinium contrast
Blood and urine toxicology screen
Electrocardiogram
Note-A benign (ie, primary) sexual headache syndrome is
likely if no abnormality is identified despite a thorough
evaluation for structural, vascular, or pharmacologic
causes.
22. Treatment
Acute symptomatic treatment —
-triptans first choice as:
•Zolmitriptan 5 mg intranasal spray
•Sumatriptan 3 mg, 4 mg, or 6 mg subcutaneous injection-
-Alternative:
•Naproxen 500 mg per os (PO; orally)
•Ketorolac 30 mg intravenous (IV) or 60 mg intramuscular
(IM)
•Metoclopramide 10 mg IV
•Prochlorperazine 10 mg IV or IM
23. Treatment
Preventive treatment —
Anticipatory pretreatment options – taken typically 30 to 60 minutes before
sexual activity.
Dosing and initial options include:
●Indomethacin 25 mg orally, titrated to effect up to 150 mg
●Propranolol 40 mg orally, titrated to effect up to 200 mg
●Sumatriptan 6 mg subcutaneous injection
Daily medications – For patients who take daily preventive therapy, we typically
start at a low initial dose, increasing gradually to effect and tolerance.
Dosing and initial options include:
●Indomethacin 25 mg orally once daily, up to maximum dose of 225 mg orally
once daily
●Propranolol 40 mg orally once daily, up to maximum dose of 240 mg orally once
daily
●Also some triptans can get some benefits
