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Exercise-Induced & Sexual Headaches
Posted June 1998
Reprinted from Chicago Medicine, December 21, 1990 and Excerpt from Book: Management of Headache and Headache Medications, Lawrence Robbins, MD

Although sex-induced headaches are generally benign, they may be a sign of a more severe neurologic problem.

Exertional headaches are frequently found in both migraine sufferers and nonheadache-prone patients. While organic pathology needs to be excluded, it has become apparent that in the vast majority of people these headaches are benign.

Exertional headaches are more common in patients over the age of 40, occurring with the same frequency in both women and men. The headache occurs just after exercise (such as weight lifting, aerobics, jogging, or sexual intercourse), and may be brief in duration, 15 minutes to 20 minutes, or prolonged, lasting tip to one day. In patients with coexisting migraine or cluster headaches, the exertional headache is usually of the same type.

Exercise headaches
While any activity that increases intracranial pressure may produce an exertional headache, certain exercises are more likely to lead to a headache. These have been weight lifting, "heading" the ball in soccer, jogging, diving, and sexual activity. The lower impact activities, such as walking, swimming, treadmilling, and biking, rarely produce exercise-induced headaches. Patients who recently begun physical fitness programs are more likely to experience exertional migraines.

Any neurologic problem that comes apparent with increasing intracranial pressure may manifest itself during sexual activity. Meningitis, subarachnoid hemorrhage, and stroke may become apparent during sex. Occasionally, headaches during sexual activity represent problems outside of the CNS, such as an obstructive lesion of the lower aorta. However, sex-induced headaches are generally benign, without intracranial or other pathology. While the term "coital cephalgia" was coined in the 1960s, other activities, such as masturbation or just getting in the position for intercourse, may produce a headache.

Sexual Headaches
The sexual headache varies in length from minutes to hours, and the severity may be mild or, more frequently, moderate to severe. The two primary pathophysiologic mechanisms involve vascular components and muscle contraction. One other patho-physiologic mechanism is the headache with low CSF pressure, noted in a few patients with sexual headaches.

The timing of the headaches is variable, but usually they are just prior to orgasm. The headache with sexual intercourse is usually occipital, but it may be generalized. Stopping intercourse when the headache begins can lessen the length or duration of the headache. It has recently been reported that sex will occasionally stop a migraine headache already in progress.

Subarachnoid hemorrhage from aneurysm or AVM, and tumors that block the ventricular outflow, such as a colloid cyst of the third ventricle, need to be excluded. Other organic pathologies to be considered are tumors of the posterior fossa, chronic subdural hematomas, basilar impression, platybasia, Arnold-Chiari, and the rare cases of pheochromocytoma, hypoglycemia, hvpertension, hyperthyroidism, COPD, meningitis, or stroke.

In the acute situation, CAT scan and lumbar puncture are important in ruling out subarachnoid hemorrhage. While MRI is not as useful in the acute situation where there is the possibility of bleeding, it is extremely useful in looking for other possibilities including tumors. For most patients, the workup of exertional headache includes checking blood pressure, checking a routine thyroid screen, and, most importantly, doing a CAT scan with infusion or an MRI of the brain. In the acute situation where subarachnoid hemorrhage is suspected, lumbar puncture is necessary if the CAT scan is negative.

Treatment of Headaches
If possible, avoiding the precipitating exercise may be useful, but for patients not willing to do this, two primary treatments may be used:
The anti-inflammatories indomethacin, or more recently, naproxen sodium. The usual dose of indomethacin is 50 mg. or 75 mg., given one to two hours prior to the activity. Naproxen sodium is either Naprosyn, 500 mg., or Anaprox DS, 550 mg., one tablet one or two hours prior to the exercise.

Propranolol has also been used, both on a daily basis and on an as-needed basis. Propranolol, 40 mg. one or two hours prior to the exercise may be used. Ergotamine, aspirin, or ibuprofen used prophylactically have been helpful.

Treatment of the headache follows the usual treatment of severe muscle contraction or migraine headaches. It involves applying cold to the head, lying down in a dark room, and taking medication. Aspirin and caffeine medications that are over-the-counter (Excedrin or Anacin), anti-inflammatory, such as naproxen sodium (Anaprox DS, one tablet) or butalbital-containing compounds, such as Fiorinal or Esgic, may be used. The generic butalbital compounds (Fiorinal and Esgic) are not nearly as effective as the brand name.

The drug treatment is similar for sexually induced headaches. It may also be helpful to look at other aspects, such as the level of anxiety of the person during the sexual activity. Occasionally, in addition to medication, counseling has been useful in patients with sexually induced headaches, particularly when there is a high level of anxiety or other psychological factors that are involved. Position is occasionally important, as the "active partner" seems to be more likely to experience sexual headache than the "passive partner"

In summary, exertional headaches may occur with a wide range of activity, and, while the overwhelming majority of these are benign, serious pathology needs to be excluded. The treatment, other than abstinence from the precipitating exercise, primarily involves the use of anti-inflammatories, such as indomethacin or naproxen sodium, or propranolol prior to the exercise. Sexual headaches may occur with several types of sexual activity, and the treatment involves, again, the use of anti-inflammatories or propranolol prior to sexual activity, with the addition of psychological counseling for selected patients.