Headache During Sex: Serious or Harmless?

Dear Dr. Dave and Dr. Dee,

For the past year my boyfriend has been getting headaches after sex. He describes them as pulsating with a lot of pressure from the top of his head to his eyes. They used to come infrequently, now he has them after every orgasm. What are some possible causes and treatments for this problem?

Signed,

Both hurting.

Dear Both,

Since your boyfriend's sex headaches have been going on for a year, they are probably benign coital headaches (see explanation below). But, because they're getting steadily worse, he needs to see a physician. Here's why:

ARE SEX HEADACHES SERIOUS OR HARMLESS?

There are basically two types of sex headaches:

The first, and most common, is the benign coital headache, which tends to occur on a regular basis during or after sex, and is relatively harmless.

The second type is the "new onset" severe headache during sex. This is a first time headache, which the patient generally characterizes as the worst headache of their life. This type of sex headache is a serious emergency until proven otherwise. Such a headache is often due to an acute brain hemorrhage or other serious condition. Fortunately, this type of first onset headache is fairly unusual, but when it does occur it can represent a life threatening emergency, which requires emergency evaluation and treatment.

BENIGN COITAL HEADACHES:

Benign coital headaches tend to occur before or during orgasm, and may persist for a period of minutes, or hang on for hours after sex. It can occur in both men and women. Although benign coital or orgasmic headaches are very painful, and obviously limit sexual enjoyment, they present no other acute threat. They are thought to result from muscle contraction, and/or blood vessel dilation, in the head and neck during sex.

WHAT CAN BE DONE FOR BENIGN COITAL HEADACHES?

Once a serious cause, such as a brain bleed, has been ruled out, benign sex headaches can be relatively easy to treat. Sometimes abstaining from sex for a couple of weeks is all that's required. If that doesn't work, then a physician may need to prescribe medication to be taken an hour or so before sex in order to prevent the onset of the headache. Beta blockers, nonsteroidal anti-inflammatories (NSAIDS), and calcium channel blockers have all been used with some success. Benign sexual headaches also seem to respond well to a decrease in stress. The good news is that with or without treatment, benign sexual headaches tend to resolve all on their own.

BRAIN HEMORRHAGE:

Brain hemorrhage may occur during sex when an abnormal blood vessel bursts, causing an acute hemorrhage over the surface of the brain (subarachnoid hemorrhage), or within the brain (intracerebral hemorrhage).

A noncontrast CT scan of the brain, which is available in most medium sized and larger emergency departments, will detect a high proportion of brain hemorrhages. But the noncontrast CT scan isn't perfect. A spinal tap (lumbar puncture) will sometimes pick up hemorrhage missed by the CT. If the CT and lumbar puncture are both nondiagnostic, and the headache is clinically suspicious for a bleed, then an invasive procedure called an arteriogram (cerebral angiogram) may be needed to make the diagnosis.

Brain bleeds comprise only a tiny percentage of all headaches, but if they are not diagnosed and treated emergently, the result can be catastrophic disability or death. That's why doctors maintain a high index of suspicion about explosive onset severe headaches, and why anyone with such a headache needs an emergency evaluation by a physician.

HOW CAN SEX CAUSE A BRAIN BLEED?

Brain bleeds, often result from the rupture of an abnormal blood vessel such as an aneurysm or AVM (arteriovenous malformation).

An aneurysm is an abnormal artery, with bulging walls, somewhat like the bulging area we sometimes see in an overinflated tire inner tube. An AVM is a tangle of abnormal communications between arteries and veins. The walls of aneurysms and AVM's are weak, compared to normal vessels, so elevated blood pressure can cause them to leak or burst. The liberation of blood around or into the brain immediately produces the explosive headache.

Since transient heart rate and blood pressure elevations occur during sex, and the walls of aneurysms and AVM's are weak, then it isn't too surprising that they sometimes rupture or leak during sex.

People are usually not aware that they have an aneurysm or AVM. It may be present for their entire life and cause no symptoms at all, until the day it leaks or ruptures.

SENTINEL BLEED: THE FIRST HEADACHE MAY GO AWAY

Sometimes brain bleeds start with a tiny leak, which may temporarily seal itself off, after which the headache may temporarily resolve. This is called a "sentinel bleed." A sentinel bleed is an important warning sign of impending rupture. It's crucial to recognize and diagnose a sentinel bleed because it provides a window of opportunity to identify and repair an aneurysm before it completely ruptures causing brain damage, or death.

SUMMARY:

On the whole, sex headaches are more often harmless than serious. But, the problem is that a small percentage is due to a serious life threatening emergency, such as a brain bleed. That's why a new onset headache during sex needs an emergency evaluation by a physician. As is often the case in medicine, the percentage chance of a bleed may be small, but if it happens to you, then it's 100%.