Exertional, cough, and sexual headaches

Abstract

The International Headache Society applies the term exertional headache to head pain precipitated by exertion. The Society recognizes cough headache and sexual headache as distinct diagnoses. All three types of headache share characteristics and mechanisms, and together may be considered as headache provoked by exertional factors ( Table 1). In distinction to more typical headaches, such as tension-type headaches or migraine, HAPEF is brief, lasting seconds to minutes, and begins immediately following the precipitating exertion. Headache provoked by exertional factors may occur by itself, or in association with headaches that are not exertional. Secondary (or symptomatic) HAPEF arises as a result of an underlying disorder; primary (or benign) HAPEF has no underlying cause. Clinicians must consider HAPEF potentially serious until appropriate investigations are undertaken. Fortunately, disorders that underlie secondary headaches usually become apparent with examination or laboratory testing. Clinical features of the headaches may also offer a clue (Table 2). Several theories have been put forth to explain the underlying mechanism of exertional, cough, and sexual headache. The leading explanation regarding all three involves exertional factors leading to a sudden increase in intracranial pressure or an inappropriate reaction in the cerebral vasculature. Because exertion may also be a migraine trigger, neural hypersensitivity, similar to migraine, may also play a role in HAPEF. The literature contains only several small case studies that deal with treatment of exertional headache, and just one double blind, placebo-controlled study. The consensus to date is that secondary HAPEF resolves if the underlying illness can be treated; primary HAPEF responds well to prophylactic treatment. Treatment strategy varies little among headaches precipitated by cough, sex, or other forms of exertion. Avoidance strategies, sometimes combined with medication (particularly indomethacin), can effectively treat headaches produced by exertional factors in most cases.

Primary Headaches Associated with Sexual Activity—some Observations in Indian Patients

“…Of the 15 male subjects with coital headache, 14 experienced pre‐orgasmic headache (BSH Type 1) and only one, a relatively elderly man, had typical orgasmic headache (BSH Type 2). This is surprising considering the fact that most previous studies concentrated more on the orgasmic headache, presumably of vascular origin, and often discussed it with other similar conditions such as exertional headache (10–13) (mentioned above). Also intriguing has been the observation that such headaches started occurring a number of years after starting an active sexual life and then, too, not on every occasion.…”

An Update on the Less-known Group of Other Primary Headaches – A Review

“…PEH is more common in young patients aged 24±11 years old (in contrast to secondary exercise headaches that mostly occur in elder patients aged 42±14 years old), but is not associated with accompanying symptoms (vomiting, diplopia). 41 Exercise headaches may be prevented by a warm-up period and good hydration. 1 Excess body weight and excessive exercise, particularly in hot weather or at high altitude, should be avoided.…”

“…50,52 Despite this, secondary causes of headaches are less common (7 % -11 %) and must be excluded: subarachnoid haemorrhage (4.5 % to 12 %), 53 arterial dissection, hydrocephalus due to Silvian aqueductal stenosis, obstruction of the lower aorta, spinal cord lesion and use of phosphodiesterase inhibitors. 29,31,41,50,53,54 Patients with sexual headache should be evaluated with brain computed tomography (CT) and lumbar puncture, if they are seen shortly (up to 3 days) after the episode. Within this time even small subarachnoid bleeding may be detected.…”

“…but stress management can be a more realistic solution. Calcium-channel blockers or 25-75 mg of indomethacin, 1 hour before sexual activity41,50 b-blockers, such as propranolol(40-200mg per day), showed also efficacy in prophylaxis 46,50. Topiramate (50 mg for 6 months) is used as prophylactic treatment against sexual headache, when b-blockers are contraindicated in patients with bronchial asthma 55.…”

Sports-related headache

“…There is no evidence-based treatment for benign exertional headaches. One of the most preferred treatments is indomethacin [10][11][12], although other nonsteroidal anti-inflammatory drugs may be equally effective. Ergotamine, methysergide, or propranolol may be used preemptively.…”