Topiramate for the Prevention of Primary Headache Associated With Sexual Activity: The Third and Fourth Case Reports

Primary Headache Associated with Sexual Activity: A Review of the Literature

PURPOSE OF REVIEW

This review summarizes the evolution in diagnosis, evaluation, and treatment of primary headache associated with sexual activity (PHASA).

RECENT FINDINGS

Despite increased access to patient information and advances in imaging, the pathophysiology of PHASA remains not fully understood. There are many secondary headaches that may present with headache during sexual activity, and a thorough workup is indicated to rule out potentially life-threatening etiologies. Many recent case series discuss the efficacy of known treatments of PHASA, as well as suggest other potential therapies for this condition including the newer CGRP-targeted therapies. Headaches during sexual activity can be worrisome events which necessitate urgent evaluation, particularly when presenting with sudden-onset and severe "thunderclap" headaches. A thorough workup including imaging should be conducted to rule out etiologies such as subarachnoid hemorrhage, reversible cerebral vasoconstrictive syndrome (RCVS), vasospasm, and dissection. PHASA is commonly comorbid with migraine, tension-type headache, exertional headache, and hypertension. PHASA can present as a dull headache that progresses with sexual excitement, or an explosive headache at or around orgasm. Pain is primarily occipital, diffuse, and bilateral. The headaches are discrete, recurrent events with bouts that typically self-resolve, but may also relapse and remit or continue chronically in some patients. PHASA can be treated preemptively with indomethacin and triptans administered prior to sexual activity, or treated prophylactically with beta-blockers, topiramate, and calcium channel blockers. CGRP-targeted therapies may provide relief in PHASA based on a few case reports, but there are no randomized controlled trials looking at specific efficacy for these therapies.

Update on headaches associated with physical exertion

BACKGROUND

Headaches associated with physical exertion include headache precipitated by coughing or other Valsalva maneuvers, headache brought on by prolonged physical exercise, sexual headaches and cardiac cephalalgia.

OBJECTIVE

To review and update the clinical characteristics, etiologies, pathophysiology and management of these headaches related to exertion.

METHODS

In depth review of the publications, both in PubMed and in the main textbooks, of the different headaches induced by physical exercise.

RESULTS

Cough, exercise and sexual headaches can be primary or secondary; therefore, complementary studies are mandatory to rule out structural lesions. However, clinical characteristics, such as an old age and response to indomethacin for cough headache or being a young male and response to beta-blockers for exercise and sexual headaches, plus a normal examination are suggestive of a primary etiology. Etiology for secondary varieties, as posterior fossa lesions for cough headache or vascular malformations for exercise and sexual headaches, are also different. Finally, headache as a distant manifestation of myocardial ischemia, also known as "cardiac cephalalgia", appears at exertion in around two-thirds of cases and typically lasts less than 30 minutes and is relieved by nitroglycerine.

CONCLUSIONS

Primary and secondary cough headache can usually be suspected based on clinical characteristics and separated from exercise and sexual headaches, which share many aspects. Cardiac cephalalgia is not necessarily an exertional headache and should be considered in adult patients with short lasting headaches and patent vascular risk factors.

Successful treatment of primary headache associated with sexual activity using erenumab: Case report

BACKGROUND

Primary headache associated with sexual activity is a rare benign headache disorder that is provoked by sexual excitement. It is a diagnosis of exclusion after the underlying secondary causes have been ruled out. The cause of this headache disorder is still unknown. Cerebral vasospasm, pericranial muscular contraction, hemodynamic and respiratory changes during sexual activity are most commonly listed as possible pathophysiological mechanisms. Several acute and prophylactic options with good clinical response have been described in the case series.

CASE REPORT

We present a case of a 30-year-old woman with primary headache associated with sexual activity and comorbid with frequent episodic migraine without aura. Both headache disorders were successfully managed with monoclonal antibody against calcitonine gene-related peptide (CGRP) receptor erenumab 70 mg.

CONCLUSION

The efficacy of erenumab in our case presumes that CGRP might also be an important mediator in facilitating primary headache associated with sexual activity.

Pleasure and Displeasure: Thunderclap Headache in a 13-Year-Old Boy

Primary headache associated with sexual activity (PHASA) is a rare headache syndrome characterized by an acute, maximally intense headache during sexual activity and/or orgasm. While rare, it is a diagnosis that is widely accepted in adults; but, scarcely documented in children and adolescents. We aim to highlight the diagnostic process of this interesting headache syndrome in the pediatric population and add to the small list of reported cases in this group. Herein, we describe the case of a 13-year-old boy who presented with thunderclap headaches (TCH) associated with sexual activity. While more commonly diagnosed in adults, PHASA should be considered in sexually active children, though more ominous diagnoses should also be contemplated prior to establishing this diagnosis.

“To sleep”, “to cough” and “to love’: Uncommon primary headaches

IntroductionThere are some physiological situations in which the individual may experience headache, such as to sleep, to cough and to love. In the first situation, "to sleep", the patient does not have headache when awake, but is awakened by pain during sleep; in the second, the act of "to cough" is a trigger for the onset of pain and finally, "to love," here, meaning sexual intercourse, can be a headache trigger.ObjectiveTo review the epidemiological, pathophysiological aspects and therapeutic management of headaches that arise when sleeping, coughing and having sexual intercourse.MethodA narrative review of literature including case reports and clinical trials were carried out. The articles were systematically obtained and assessed by the authors.ResultsThree primary forms considered rare were identified: hypnic headache, primary cough headache and primary headache associated with sexual activity. Hypnic headache occurs only during sleep, predominantly in women after 50 years of age. It was described in 1988 by Raskin, and has a prevalence ranging from 0.07% to 0.22%. Primary cough headache is triggered by coughing or another Valsalva maneuver and is more common in men over40 years of age. It was first described by Jules Tinel and has a prevalence of 0.4% to 1.2%. Primary headache associated with sexual activity occurs during sexual intercourse. It is more frequent in men after 40 years of age. It was described in the second century of the Christian era, by the Persian physician Avicenna. Its prevalence ranges from 0.9% to 1.6%.ConclusionPrimary headaches in the "to sleep", "to cough", and "to love" group are rare. They predominate in men, after 40 years of age, are of short duration, can be primary or secondary and have a therapeutic response to indomethacin.

Headache Associated with Sexual Activity-A Narrative Review of Literature

Headache associated with sexual activity (HAWSA) has accompanied humanity since ancient times. However, it is only since the 1970s that it has become the subject of more extensive and detailed scientific interest. The purpose of this review is to provide an overview of the development of the concept of HAWSA, its clinical presentation, etiopathogenesis, diagnosis and treatment especially from the research perspective of the last 20 years. Primary HAWSA is a benign condition, whose etiology is unknown; however, at the first occurrence of headache associated with sexual activity, it is necessary to exclude conditions that are usually immediately life-threatening. Migraine, hypnic headache or hemicrania continua have been reported to co-occur with HAWSA, but their common pathophysiologic basis is still unknown. Recent advances in the treatment of HAWSA include the introduction of topiramate, progesterone, and treatments such as greater occipital nerve injection, arterial embolization, and manual therapy. Whether these new therapeutic options will stand the test of time remains to be seen.