Slow pain coming: A brief look at benign masturbatory cephalalgia

In a previous blog, I examined the medical research on individuals that suffer severe headaches as a result of having sex (known in the clinical and medical literature as ‘coital cephalalgia’ and ‘benign coital headache’). In such circumstances, the headache typically occurs at the brink of orgasm. While researching that particular blog, I also came across a number of papers (mainly case studies) that reported that these types of headache could also occur during masturbation (known as ‘benign masturbatory cephalalgia’ (BMC). (Here, the term ‘benign’ defines a primary headache syndrome not caused by any intracranial disorder).

The first paper that I read on BMC was a case account by Dr. Frederick Vincent in a 1982 issue the Archives of Neurology. Although benign orgasmic cephalgia had already been well described in the medical literature (particularly among males), Dr. Vincent reported the case of a 28-year old woman with orgasmic cephalalgia that developed during masturbation. This was reported by Dr. Vincent as the first ever case of BMC. The young woman “suffered a sudden throbbing occipital headache as she became orgasmic by masturbation”. The headache lasted an hour accompanied by mild nausea, but no other neurologic symptoms. As a result of this case, Dr. Vincent argued that the term ‘coital cephalagia’ should be dropped and simply called ‘orgasmic cephalagia’ irrespective of whether the headache was self-induced (i.e., masturbatory) or caused by having sexual intercourse.

Following the publication of Vincent’s case study, Dr. James Lance immediately responded in the same journal saying that he had reported the cases of three of his patients whose headaches were brought on by masturbation. Lance also agreed that the term coital cephalalgia was too restrictive, but then argued that:

“Orgasmic cephalalgia ignores the premonitory headache that may build up as sexual excitement mounts before orgasm. Benign sex headache (using ‘sex’ in the popular sense) is an all-embracing, albeit unpoetic, term and is comparable with benign cough headache. It is worth emphasizing that neither condition is always benign”.

A 2004 case study published by Dr. Marcelo Valenca and colleagues in the journal Headache: The Journal of Head and Face Pain noted that only five cases of patients with thunderclap headache precipitated by sexual activity had been identified in the medical literature. In their paper, they reported the case of a 44-year-old woman that suffered both coital and masturbatory headaches during orgasm. After carrying out a number of medical tests they concluded that the women had experienced cerebral arterial narrowing shortly after her orgasmic headache attacks and that this “supported the hypothesis that segmental vasospasm may exert a role in the pathogenesis of this uncommon type of headache”.

A number of papers on orgasmic cephalagia have been published by Dr. Achim Frese and his colleagues. In a 2004 issue of the journal Neurology, Frese led a study examining the demography, clinical features, and comorbidity of headache associated with sexual activity (HSA) in interviews of 51 participants. They reported that HSA was not dependent on specific sexual habits and most often occurred during sexual activity with the usual partner (94%) and during masturbation (35%).

A 1998 paper by Dr. Daniel Jacome in Headache: The Journal of Head and Face Pain reported something slightly different but related to BMC. More specifically, Dr. Jacome reported the cases of two single men described as having masturbatory-orgasmic extracephalic pain (i.e., an ice-pick like pain that occurred in the neck of one of the men, and in the groin and genitalia of the other). Both men had pre-existing medical conditions (i.e., compressive spondylitic cervical myelopathy in the first case, and a tethered cord and intraspinal lipoma in the second case). These two unusual cases represent examples of extracephalic ice picklike pain triggered by sexual activity, in the absence of orgasmic cephalgia.

A more recent 2012 paper by Dr. Amy Gelfand and Dr. Peter Goadsby in the journal Pediatrics examined primary sexual headaches in two male adolescents. One of the two cases (a 16-year-old boy) developed headaches at the moment of orgasm, building up in intensity over 5 to 10 seconds, and then continuing for between 10 seconds to 2 minutes before stopping. The authors also reported that headaches occurred irrespective of whether orgasm was achieved through intercourse or masturbation. He was not formally treated because after several months, the patient no longer experienced the headaches with orgasm.

Finally, a 2006 paper by Dr. Ambar Chakravarty in the journal Cephalalgia examined data from 24 Indian patients (18 males and 6 females) over a 20-year period (1985–2004) that suffered preorgasmic headaches. Dr. Ambar reported that three of the youngest male patients (aged 19–23 years) had experienced masturbatory headache. One of the female patients (aged 30 years) only experienced orgasmic headache during masturbation (i.e., she never experienced headaches during sexual intercourse).

Summarizing the medical literature on orgasmic cephalagia as a whole (i.e., on coital and masturbatory cephalagia), the 2012 paper by Gelfand and Goadsby concluded that:

“The orgasmic subtype of primary sex headache is more common than the gradual onset pre-orgasm type and has received more attention in the medical literature…In the orgasmic subtype, headache onset is explosive and severe. Orgasms achieved through either sexual intercourse or masturbation can trigger the headache. The headache location is variable, although most often bilateral. The quality is typically pounding or throbbing. Duration of headache ranges from minutes to several hours. Age at onset is classically in the late thirties or early forties, and there is a male predominance. The natural history of the disorder is that after several months it typically remits, although some patients will have a chronic course lasting over a year, and recurrences are possible”.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Chakravarty, A. (2006). Primary headaches associated with sexual activity—some observations in Indian patients. Cephalalgia, 26(2), 202-207.

Frese, A., Eikermann, A., Frese, K., Schwaag, S., Husstedt, I. W., & Evers, S. (2003). Headache associated with sexual activity: Demography, clinical features, and comorbidity. Neurology, 61(6), 796-800.

Gelfand, A.A., & Goadsby, P.J. (2012). Primary sex headache in adolescents. Pediatrics, 130(2), e439-e441.

Jacome, D.E. (1998). Masturbatory-orgasmic extracephalic pain. Headache: Journal of Head and Face Pain, 38(2), 138-141.

Lance, J. W. (1976). Headaches related to sexual activity. Journal of Neurology, Neurosurgery & Psychiatry, 39(12), 1226-1230.

Lance, J. W. (1983). Benign masturbatory cephalalgia. Archives of Neurology, 40(6), 393.

Østergaard, J. R., & Kraft, M. (1992). Benign coital headache. Cephalalgia, 12(6), 353-355.

Redelman, M. (2010). What if the ‘sexual headache’ is not a joke. British Journal of Medical Practitioners, 3(1), 40-44.

Valenca, M. M., Valenca, L. P., Bordini, C. A., Da Silva, W. F., Leite, J. P., Antunes‐Rodrigues, J., & Speciali, J. G. (2004). Cerebral vasospasm and headache during sexual intercourse and masturbatory orgasms. Headache: The Journal of Head and Face Pain, 44(3), 244-248.

Vincent, F. M. (1982). Benign masturbatory cephalalgia. Archives of Neurology, 39(10), 673.

Coming to a head-ache: A brief look at coital cephalalgia

“Not tonight dear, I’ve got a headache” is a staple (and somewhat stereotypical) phrase typically used by women in various television sitcoms to politely turn down their husband’s sexual advances. However, there is a small minority of individuals where sexual activity can actually trigger headaches (known in the clinical and medical literature as ‘coital cephalalgia’ and ‘benign coital headache’) often occurring at the brink of orgasm. (Here, the term ‘benign’ defines a primary headache syndrome not caused by any intracranial disorder). Often characterized by sufferers as a “severe pain behind the eyes” it can be short-term or long-lasting (up to days in extreme cases), and can affect both sexes across the age spectrum. According to the National Headache Foundation, around 1 in 5 women and 1 in 20 men experience “exertional headaches” (i.e., headaches caused by increased blood pressure in the brain that typically occurs during exercise). Such exercise can in a minority of cases include sexual activity.

One of the earliest recorded cases of coital cephalalgia – at least one of the earliest I found when I did an online literature search – was published in a 1974 issue of the Irish Journal of Medical Science by Dr. Edward Martin. He published six case studies of “a benign syndrome of recurrent headache during sexual intercourse”. For instance, one of his cases was a 42-year old male engineer that claimed he suffered migraine headaches during sex (lasting from 10 to 60 minutes). It first occurred just two weeks after marrying his wife and then carried on at regular intervals. The headache always occurred “abruptly at the onset of orgasm”. After about a year, the headaches subsided to the point where they were only occasional. (Other articles I have read say that the first paper published on this topic was by Dr. J.W. Lance who wrote a paper entitled ‘Headaches related to sexual activity’ in the Journal of Neurology, Neurosurgery, and Psychiatry. However, that paper was published two years after the one by Dr. Martin). Another early paper published by Dr. M. Porter and Dr. J. Jankovic, in a 1981 issue of the Archives of Neurology reported eight cases of benign coital cephalalgia (BCC), “an acute headache that is time related to sexual intercourse” (and a variant of migraine). The authors reported that all eight sufferers were successfully treated with propranolol hydrochloride.

In a 1988 issue of Cephalalgia, Dr. J.M. Martinez and his colleagues reported three cases of benign coital cephalalgia (all of who had a history of migraine). Comparing their own cases with those that had previously been published, they concluded that such sex-related headaches may have resulted from heart problems (“ischaemic disturbances”) triggered by “haemodynamic changes occurring in orgasm”. There is also some evidence that the condition may have a partly genetic basis as a 1986 paper By Dr. D.R. Johns in the Archives of Neurology reported four cases of benign sexual headache (BSH) in four sisters from the same family. He reported the most severely affected of the sisters was successfully treated with propranolol hydrochloride (as reported above), and that BSH was a variant of migraine.

In a 2005 review paper by Polish medic Dr. I. Domitrz, I. (published in the journal Ginekologia Polska) on primary headaches associated with sexual activity], it was noted that BCH was rare and that:

“The pathogenesis of this type of headache remains unknown. Clinical manifestation is typical and connected with three phases of sexual activity. Coital cephalalgia is divided into two subtypes: preorgasmic and orgasmic headache. Some authors specify the third type–postural type. Preorgasmic headache starts as a dull bilateral ache and increases with sexual excitement. Orgasmic headache has sudden, intense character and occurs at orgasm. Postural headache has been reported to develop after coitus”.

In a 1992 issue of the journal Cephalalgia, Danish doctors Dr. J.R. Østergaard and Dr. M. Kraft studied the natural history of patients with a diagnosis of benign coital headache (BCH) that presented themselves for treatment in their clinic over a 13-year period (1978-1991). Of the 32 patients that had been treated for BCH, 26 of them participated in their follow-up study. They reported that 13 patients (50% of their sample) had recurrent attacks of coital headaches separated by intervals of up to 10 years. Of these 13, eleven of them “suffered a concomitant primary headache whereas this was present in only one of those patients without recurrent attacks of coital headache”. Apart from one patient who suffered blurred vision, the headaches were not too severe as there were no reports of vomiting, visual disturbances, sensory/motor disturbances, or unconsciousness. The paper concluded that BCH can clearly be “distinguished from headaches due to cerebral aneurysm or arteriovenous malformation rupture. The presence of a concomitant primary headache syndrome is a risk-factor for recurrence of coital headache”.

Arguably the most well known researcher in the field of sexual headaches is the German Dr. Achim Frese who has published a whole series of papers with his team on the topic. In a 2005 review paper in the journal Practical Neurology, Frese and his colleague Dr. Stefan Evers noted that:

“The frequency of headache associated with sexual activity is unknown. In the only population-based epidemiological study, the lifetime prevalence was about 1% with a wide confi dence interval, similar to the frequency of benign cough headache and benign exertional headache (Rasmussen & Olesen 1992). Very likely, the frequency is underestimated because patients often feel too embarrassed to report intimate details about their sexual activities. We estimate that patients with headache associated with sexual activity account for about 1% of all headache patients who are referred to our supraregional headache clinics”.

In 2003, Frese and colleagues examined the demographic and clinical features of headaches associated with sexual activity (HSA) in the journal Neurology. Between Over a five-year period (1996-2001), they interviewed 51 patients with the diagnosis of HAS. The average age of onset was just under 40 years of age and there were approximately three times more males with HSA. They also reported that 11 of their participants had HSA type 1 (i.e., dull subtype), which gradually increased with increasing sexual excitement. The remaining 40 participants had HSA type 2 (i.e., explosive subtype). There were no participants with HSA type 3 (i.e., postural subtype). HSA wasn’t dependent on any specific sexual habits and most often occurred during sexual activity with their usual partner (94%) and during masturbation (35%). There were no differences between HSA types 1 and 2 in relation to demographic factors, clinical features, or comorbidity, except for a higher probability of stopping the attack by breaking off sexual activity in HSA type 1.

In 2007, Frese and his colleagues published a paper in the journal Cephalagia looking at the prognosis and treatment of HSA. In this study they followed up 60 HSA cases in an eight-year period (1996-2004). Of the 45 cases that had experienced just single attacks prior to baseline examination, the vast majority (n=37) had no further attacks. The most effective treatment was the use of beta-blockers. They also reported that:

“Seven patients suffered from at least one further bout with an average duration of 2.1 months. One patient developed a chronic course of the disease after an episodic start. Of the 15 patients with chronic disease at the first examination, seven were in remission and five had ongoing attacks at follow-up…Episodic HSA occurs in approximately three-quarters and chronic HSA in approximately one-quarter of patients. Even in chronic HAS, the prognosis is favourable, with remission rates of 69% during an observation period of 3 years”.

In an earlier 2003 paper (also in the journal Cephalgia), Frese and colleagues examined the cognitive processes of people with type 2 HSA (i.e., the explosive subtype) by measuring event-related potentials (ERPs). They measured visual ERPs in 24 individuals with HSA outside the headache period. These individuals were then compared to a control group (age- and sex-matched). They found that those with HSA type 2 have a loss of cognitive habituation as measured by ERP and that their ERP patterns were very similar to that in observed migraine sufferers.

Earlier this year, Frese and colleagues published an observational study in the journal Cephalagia examining whether having sex could actually alleviate headaches (including migraines). From their previous research, they noted that headaches associated with sexual activity were well-known but that some case reports in the literature suggest that sexual activity during a headache might relieve the pain (in at least some patients). The research team sent a questionnaire to 800 migraine patients and 200 patients with other kinds of headache (called ‘cluster’ headaches). The paper reported that:

“In migraine, 34% of the patients had experience with sexual activity during an attack; out of these patients, 60% reported an improvement of their migraine attack (70% of them reported moderate to complete relief) and 33% reported worsening. In cluster headache, 31% of the patients had experience with sexual activity during an attack; out of these patients, 37% reported an improvement of their cluster headache attack (91% of them reported moderate to complete relief) and 50% reported worsening. Some patients, in particular male migraine patients, even used sexual activity as a therapeutic tool. The majority of patients with migraine or cluster headache do not have sexual activity during headache attacks. Our data suggest, however, that sexual activity can lead to partial or complete relief of headache in some migraine and a few cluster headache patients”

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Chakravarty, A. (2006). Primary headaches associated with sexual activity—some observations in Indian patients. Cephalalgia, 26, 202-207

Domitrz, I. (2005). Primary headache associated with sexual activity]. Ginekologia polska, 76, 995-999

Frese, A., Eikermann, A., Frese, K., Schwaag, S., Husstedt, I. W., & Evers, S. (2003). Headache associated with sexual activity Demography, clinical features, and comorbidity. Neurology, 61, 796-800.

Frese, A., & Evers, S. (2005). Primary headache syndromes associated with sexual activity. Practical Neurology, 5, 350-355.

Frese, A., Frese, K., Ringelstein, E. B., Husstedt, I. W., & Evers, S. (2003). Cognitive processing in headache associated with sexual activity. Cephalalgia, 23, 545-551

Frese, A., Gantenbein, A., Marziniak, M., Husstedt, I. W., Goadsby, P. J., & Evers, S. (2006). Triptans in orgasmic headache. Cephalalgia, 26, 1458-1461

Frese, A., Rahmann, A., Gregor, N., Biehl, K., Husstedt, I. W., & Evers, S. (2007). Headache associated with sexual activity: prognosis and treatment options. Cephalalgia, 27, 1265-1270

 

Hambach, A., Evers, S., Summ, O., Husstedt, I. W., & Frese, A. (2013). The impact of sexual activity on idiopathic headaches: An observational study. Cephalalgia, 33, 384-389

Johns, D. R. (1986). Benign sexual headache within a family. Archives of Neurology, 43, 1158-1160.

Lance, J.W. (1976). Headaches related to sexual activity. Journal of Neurology, Neurosurgery and Psychiatry. 39, 1226-30.

Martin, E. A. (1974). Headache during sexual intercourse (coital cephalalgia). Irish Journal of Medical Science, 143, 342-345.

Martinez, J. M., Roig, C., & Arboix, A. (1988). Complicated coital cephalalgia: three cases with benign evolution. Cephalalgia, 8, 265-268

Ostergaard, J. R., & Kraft, M. (1992). Benign coital headache. Cephalalgia, 12, 353-355

Pascual, J., Iglesias, F., Oterino, A., Vazquez-Barquero, A., & Berciano, J. (1996). Cough, exertional, and sexual headaches An analysis of 72 benign and symptomatic cases. Neurology, 46, 1520-1524

Porter, M. & Jankovic, J. (1981). Benign coital cephalalgia: differential diagnosis and treatment. Archives of Neurology, 38(11), 710-712.

Rasmussen, B.K. & Olesen, J. (1992) Symptomatic and nonsymptomatic headaches in a general population. Neurology, 42, 1225–31.

Silbert, P. L., Edis, R. H., Stewart-Wynne, E. G., & Gubbay, S. S. (1991). Benign vascular sexual headache and exertional headache: interrelationships and long-term prognosis. Journal of Neurology, Neurosurgery and Psychiatry, 54, 417-421