Diagnosis and classification of headache associated with sexual activity using a composite algorithm: A cohort study

Abstract

Background To differentiate primary headache associated with sexual activity from other devastating secondary causes. Methods In this prospective cohort, we recruited consecutive patients with at least 2 attacks of headache associated with sexual activity from the headache clinics or emergency department of a national medical center from 2005 to 2020. Detailed interview, neurological examination, and serial thorough neuroimaging including brain magnetic resonance imaging and magnetic resonance angiography scans were performed on registration and during follow-ups. Patients were categorized into four groups, i.e. primary headache associated with sexual activity, reversible cerebral vasoconstriction syndrome, probable reversible cerebral vasoconstriction syndrome, and other secondary headache associated with sexual activity through a composite clinic-radiological diagnostic algorithm. We compared the clinical profiles among these groups, including sex, age of onset, duration, quality, and clinical course (“chronic” indicates disease course ≥ 1 year). In addition, we also calculated the score of the reversible cerebral vasoconstriction syndrome2, a scale developed to differentiate reversible cerebral vasoconstriction syndrome from other intracranial vascular disorders. Results Overall, 245 patients with headache associated with sexual activity were enrolled. Our clinic-radiologic composite algorithm diagnosed and classified all patients into four groups, including 38 (15.5%) with primary headache associated with sexual activity, 174 (71.0%) with reversible cerebral vasoconstriction syndrome, 26 (10.6%) with probable reversible cerebral vasoconstriction syndrome, and 7 (2.9%) with other secondary causes (aneurysmal subarachnoid hemorrhage (n = 4), right internal carotid artery dissection (n = 1), Moyamoya disease (n = 1), and meningioma with hemorrhage (n = 1)). These four groups shared similar clinical profiles, except 26% of the patients with primary headache associated with sexual activity had a 3 times greater chance of running a chronic course (≥ 1 year) than patients with reversible cerebral vasoconstriction syndrome. Of note, the reversible cerebral vasoconstriction syndrome2 score could not differentiate reversible cerebral vasoconstriction syndrome from other groups. Conclusion Our composite clinic-radiological diagnostic algorithm successfully classified repeated headaches associated with sexual activity, which were predominantly secondary and related to vascular disorders, and predicted the prognosis. Primary headache associated with sexual activity and reversible cerebral vasoconstriction syndrome presented with repeated attacks of headache associated with sexual activity may be of the same disease spectrum.

Pathophysiology of reversible cerebral vasoconstriction syndrome

“…Patients often avoid encountering these common daily activities to prevent themselves from the terrifying headaches. These headaches may last for hours long per attack and recur for multiple times within 2–3 weeks of disease onset [ 2 , 15 , 17 , 25 ]. Abrupt blood pressure surges accompanying headache attacks can be seen in more than one-third of patients [ 2 , 14 , 15 ].…”

Update on headaches associated with physical exertion

“…As stated for exercise headache, and despite that less than one out of five cases are secondary, explosive sexual headache should be considered as a warning symptom and investigated. The secondary causes of sexual headache include subarachnoid hemorrhage, reversible cerebral vasoconstriction syndrome, cervical or intracranial arterial dissection, hypertensive crisis and hydrocephalus (6,7,(38)(39)(40). In addition to structural (CT/MRI) brain imaging studies, considering the high proportion of vascular lesions in secondary sexual headache, comprehensive vascular imaging of the head and neck is highly recommended.…”

“…Studies have shown that subarachnoid hemorrhage precipitated by coitus occurs in 4-12% of all cases with saccular aneurysm and in 4.1% of patients with arterio-venous malformations (11,41). When the patient experiences several episodes of explosive headache during sexual activities, reversible cerebral vasoconstriction syndrome should always be considered (40). Because vasoconstrictions may not be observed at the early stage of this syndrome, follow-up studies may be needed (Figure 3, Table 3).…”

Update on primary headache associated with sexual activity and primary thunderclap headache

“…The lifetime prevalence of headache triggered by sexual activity is estimated to be 1-1.6% in two population-based studies (11,12). There is a male preponderance, with male to female ratios of approximately 2:1 to 4:1, and it typically first occurs in their midthirties to mid-forties (10,(13)(14)(15). Intercourse (83-95%) is the most frequently reported sexual act causing headache, followed by masturbation (14-35%) (3,10,16).…”

“…Primary HSA is predominantly bilateral (61-80%), occipital (58-80%), and with explosive (61-80%) and throbbing (50-90%) sensation (1,10,13,15). The headache lasts several minutes to 24 hours in most patients (13,15), and may be associated with nausea, vomiting, phonophobia, or photophobia, but without autonomic or vegetative symptoms (1,10,13,15). Some patients 1. increasing in intensity with increasing sexual excitement 2. abrupt 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 may have comorbidities of hypertension, migraine, or tension-type headache (10,13,15).…”