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Specific limb: A brief look at ‘restless legs syndrome’

Those that know me well often comment that I have a general inability to sit still and that I am a ‘fidget’. (This is not necessarily a bad thing and in fact there are some positives to fidgeting that I outlined in a previous blog on bad behaviours that are sometimes good for you). There is certainly some truth to the observation that I fidget but sometimes the fidgeting is out of my control. Every few weeks my right lower leg appears to take on a life of its own and I will get strange (uncomfortable) sensations (such as tingling, itching, and aching, and occasionally cramp-like feelings) that force me to move my right leg and foot around. It only happens when I am in a resting and relaxing state and usually lasts about 30 minutes (but can occasionally last much longer). On occasions it disrupts my work and sleep but I find that just getting up and moving around is sometimes enough to alleviate the uncomfortable feelings.

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A few years ago I Googled my ‘symptoms’ and was surprised to find that I am not the only person who appears to experience such effects and that there is a whole medical literature on what has been termed ‘restless legs syndrome’ although in my case it would be in a singular rather than plural form). I’ve had the condition for about 15 years now and it may be related to some of the medication I take for an unrelated chronic degenerative health condition that I have. According to the Wikipedia entry on restless legs syndrome (RLS):

“The first known medical description of RLS was by Sir Thomas Willis in 1672. Willis emphasized the sleep disruption and limb movements experienced by people with RLS…The term ‘fidgets in the legs’ has also been used as early as the early nineteenth century. Subsequently, other descriptions of RLS were published, including those by Francois Boissier de Sauvages (1763), Magnus Huss (1849), Theodur Wittmaack (1861), George Miller Beard (1880), Georges Gilles de la Tourette (1898), Hermann Oppenheim (1923) and Frederick Gerard Allison (1943). However, it was not until almost three centuries after Willis, in 1945, that Karl-Axel Ekbom (1907–1977) provided a detailed and comprehensive report of this condition in his doctoral thesis, Restless legs: clinical study of hitherto overlooked disease. Ekbom coined the term “restless legs” and continued work on this disorder throughout his career. He described the essential diagnostic symptoms, differential diagnosis from other conditions, prevalence, relation to anemia, and common occurrence during pregnancy. Ekbom’s work was largely ignored until it was rediscovered by Arthur S. Walters and Wayne A. Hening in the 1980s. Subsequent landmark publications include 1995 and 2003 papers, which revised and updated the diagnostic criteria”.

As well as being referred to as RLS, it is sometimes referred to as Willis-Ekbom Disease or Willis-Ekbom Syndrome. Since being ‘rediscovered’ in the 1980s, there have been a lot of scientific papers published on the phenomenon although many of these are medical case studies (I don’t think my own experiences are extreme enough or strong enough to appear in any medical textbook. The Wikipedia entry on RLS provides a good summary of what is known medically and empirically:

“Restless legs syndrome (RLS) is a disorder that causes a strong urge to move one’s legs. There is often an unpleasant feeling in the legs that improves somewhat with moving them. Occasionally the arms may also be affected. The feelings generally happen when at rest and therefore can make it hard to sleep. Due to the disturbance in sleep, people with RLS may have daytime sleepiness, low energy, irritability, and a depressed mood. Additionally, many have limb twitching during sleep. Risk factors for RLS include low iron levels, kidney failure, Parkinson’s disease, diabetes, rheumatoid arthritis, and pregnancy. A number of medications may also trigger the disorder including antidepressants, antipsychotics, antihistamines, and calcium channel blockers. There are two main types. One is early onset RLS which starts before age 45 [years], runs in families and worsens over time. The other is late onset RLS which begins after age 45 [years], starts suddenly, and does not worsen. Diagnosis is generally based on a person’s symptoms after ruling out other potential causes… Females are more commonly affected than males and it becomes more common with age…Some doctors express the view that the incidence of restless leg syndrome is exaggerated by manufacturers of drugs used to treat it. Others believe it is an under-recognized and undertreated disorder…An association has been observed between attention deficit hyperactivity disorder (ADHD) and RLS or periodic limb movement disorder. Both conditions appear to have links to dysfunctions related to the neurotransmitter dopamine, and common medications for both conditions among other systems, affect dopamine levels in the brain”.

According to a review by Dr. Richard Allen and Dr. Christopher Earley in the Journal of Clinical Neurophysiology, RLS affects 2.5-15% of the US population. In another review on sleep disorder in the journal American Family Physician, Dr. Kannan Ramar and Dr. Eric Olson reported that RLS is typically characterized by four essential features: These are:

“(1) the intense urge to move the legs, usually accompanied or caused by uncomfortable sensations (e.g., “creepy crawly,” aching) in the legs; (2) symptoms that begin or worsen during periods of rest or inactivity; (3) symptoms that are partially or totally relieved by movements such as walking or stretching; and (4) symptoms that are worse or only occur in the evening or at night”.

Various online articles and papers report a variety of potential treatments based on the notion that RLS might be caused by a dopamine imbalance in the body. Some medics advise a regular sleep routine (such as that advised for those with insomnia), and cutting out the drinking of alcohol and the smoking of cigarettes. Pharmacological treatments include the use of drugs that are also used in the treatment of Parkinson’s disease such as L-DOPA and pramipexole, and the use of magnesium sulphate therapy (as reported in a 2006 paper in the Journal of Clinical Sleep Medicine – magnesium is known to be a natural muscle relaxant). In a 2011 issue of the journal Sleep Medicine, In an online article about RLS, Dr Michael Platt, author of the 2014 book Adrenalin Dominance, claims that RLS sufferers can be treated using a progesterone cream:

“Excess adrenalin during the night can cause restless leg syndrome. People often have associated symptoms also resulting from elevated adrenalin, such as teeth grinding, the need to urinate, and tossing and turning, and they often awaken in the morning with low back pain. Characteristically, RLS patients have an excess of adrenaline, may toss and turn all night, be quick to anger, might be workaholics, will usually have fibromyalgia (aches and pains – low back, side of the hips, and grind their teeth), they might drink too much, and will be hypoglycemic (sleepy between 3-4 p.m. or when in a car), and so on. There is an associated over-production of insulin and an under-production of progesterone…[By using a progesterone cream] I have had 100% success with eliminating RLS by getting hormones into balance, often within the first week. Patients feel more relaxed, they can sleep at night, rage disappears, and they can focus more easily”.

Dr. Luis Marin and his colleagues reported a different treatment for RLS altogether. They reported the case of a 41-year-old male RLS sufferer who after being on medication for RLS discovered his own solution – having sex. Following sex, the man reported that all RLS symptoms would disappear. Marin and colleagues speculated that the release of dopamine following orgasm might alleviate RLS symptoms. This appears to be a reasonable speculation given the findings of research published in the Journal of Neuroscience by Dr. Gert Holstege and his colleagues who examined brain activation at the point of ejaculation. In their paper they reported the similarity between ejaculation and using heroin in terms of brain activation:

“We used positron emission tomography to measure increases in regional cerebral blood flow during ejaculation compared with sexual stimulation in heterosexual male volunteers. Manual penile stimulation was performed by the volunteer’s female partner. Primary activation was found in the mesodiencephalic transition zone, including the ventral tegmental area, which is involved in a wide variety of rewarding behaviors. Parallels are drawn between ejaculation and heroin rush”.

It could well be that the increase in dopamine following ejaculation acts in a similar way to the medications that are given to RLS sufferers. Of all the treatments for RLS that I have read about, I think I know which one I would prefer!

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Allen, R.P., & Earley, C.J. (2001). Restless legs syndrome: A review of clinical and pathophysiologic features. Journal of Clinical Neurophysiology, 18(2), 128-147.

Bartell S1, Zallek S. Intravenous magnesium sulfate may relieve restless legs syndrome in pregnancy. Journal of Clinical Sleep Medicine, 15, 187-188.

Chaudhuri, K.R., Appiah-Kubi, L.S., & Trenkwalder, C. (2001). Restless legs syndrome. Journal of Neurology, Neurosurgery & Psychiatry, 71(2), 143-146.

Ekbom, K., & Ulfberg, J. (2009). Restless legs syndrome. Journal of Internal Medicine, 266(5), 419-431.

Holstege, G., Georgiadis, J. R., Paans, A. M., Meiners, L. C., van der Graaf, F. H., & Reinders, A. S. (2003). Brain activation during human male ejaculation. Journal of Neuroscience, 23(27), 9185-9193

Leschziner, G., & Gringras, P. (2012). Restless legs syndrome. British Medical Journal, 344, e3056.

Marin, L.F., Felicio, A.C., & Prado, G.F. (2011). Sexual intercourse and masturbation: Potential relief factors for restless legs syndrome? Sleep Medicine, 12(4), 422.

Ondo, W. G. (2009). Restless legs syndrome. Neurologic Clinics, 27(3), 779-799.

Ramar, K; Olson, EJ (Aug 15, 2013). Management of common sleep disorders. American Family Physician, 88, 231–238.

Satija, P., & Ondo, W. G. (2008). Restless legs syndrome. CNS Drugs, 22(6), 497-518.

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

Sneezy does it: Sex, sneezing, and sneezing fetishes

Woman: (sneezes and moans several times)

Man: “Excuse me, but is everything OK?”

Woman: “Yes, it’s just that I have this condition where every time I sneeze I have an orgasm.”

Man: “Are you taking anything for it?”

Woman: (smiling) “Yes. Pepper.”

Apologies for starting this blog with an old joke but I thought it was a good way to bring up the relationship between sex and sneezing. There are reports in the medical and psychological literature dating back to the 1890s of sexually induced sneezing in both men and women. The phenomenon is characterized by sneezing during sexual arousal and/or orgasm. In such cases, these individuals sneeze as a direct result of sexual thoughts, arousal, intercourse, and/or orgasm. Furthermore, the sneezing may occur at any point during a sexual experience, and most importantly occurs independently of any external nasal stimuli or allergens.

The first verified report of the phenomenon was thought to be in 1898 when John Noland Mackenzie wrote about the phenomenon (“The physiological and pathological relations between the nose and sexual apparatus of man”) in the Journal of Laryngology, Rhinology and Otology. A few years later (1901) reference was also made to the condition in George Gould and Walter Pyle’s Anomalies and Curiosities of Medicine. I managed to track down the original quote about a man:

“who, when prompted to indulge in sexual intercourse, was immediately prior to the act seized with a fit of sneezing. Even the thought of sexual pleasure with a female was sufficient to provoke this peculiar idiosyncrasy”.

More recently, and based an a paper submitted to the American Medical Association, Dr. Jeffrey Wald, a specialist is asthma and allergies, was quoted in the US newspaper Pittsburgh Post-Gazette (September 6, 1988) about the of case of an American middle aged man who continuously sneezed following sex. He attributed the sneezing to “vasomotor rhinitis”, a condition in which the nasal passages are chronically inflamed (and characterized by hyperactive or imbalanced control of the central nervous system responses).

Even more recently, I read an iteresting paper by Dr. Mahmood Bhutta (Wexham Park Hospital, Slough, UK) and Dr. Harold Maxwell (West Middlesex University Hospital, Middlesex, UK) entitled Sneezing induced by sexual ideation or orgasm” published in a 2008 issue of the Journal of the Royal Society of Medicine. Bhutta and Maxwell’s paper cited a case from 1972, a letter to the Journal of the American Medical Association involving a 69-year-old man who suffered severe bouts of sneezing after orgasm or whenever he thought of sex.

In their paper, it was noted that both men and women were using online forums to seek out help or explanations for their experienced phenomenon. These people often felt embarrassed about bringing up the matter with the medical profession, and preferred to seek help and advice anonymously. They also reported on these online data and noted (i) three people who claimed they always sneezed after orgasm, and (ii) 17 people who reported that they sneezed immediately when they thought about sex. They speculated that the link between sex, orgasm and sneezing was most likely caused by a fault in the autonomic nervous system (i.e., the part of the nervous system that is involved with heart rate, blood flow and digestion). They argued that the nerves that control breathing, blood pressure, pupil construction, sneezing and digestion run close to each other in the brain stem. They speculated that light-sensitive sneezing and sex-related sneezing occurred when these signals became “muddled”. Dr. Bhutta told the BBC in an interview:

“[The relationship between orgasm and sneezing] certainly seems odd, but I think this reflex demonstrates evolutionary relics in the wiring of a part of the nervous system called the autonomic nervous system. This is the part beyond our control, and which controls things like our heart rate and the amount of light let in by our pupils. Sometimes the signals in this system get crossed, and I think this may be why some people sneeze when they think about sex”.

Dr. Bhutta also told the BBC that embarrassment or social inhibition may have prevented others from admitting the problem to the medical or psychological community. Another potential explanation may relate the fact that – like genitalia – the nose also has vascular (erectile) tissue, which has the capacity to become engorged during sexual arousal, and triggering a sneeze. Others have noted the ejaculatory-like qualities of the sneeze, and 1980s television ‘sexpert’ Dr. Ruth (Westheimer) observed that “an orgasm is just a reflex, like a sneeze”.

On a related issue, there is also a condition that has been coined “honeymoon rhinitis” in which men and women experience nasal irritation and inflammation of the mucous membrane inside the nose during sex. Spanish medics led by Dr J. Monteseirin published a small article in a 2001 issue of the journal Allergy. They reported a study of 23 allergy sufferers (9 women and 14 men), all of whom had experienced sneezing, rhinorrhea, and nasal obstruction immediately after (but never before or during) sexual intercourse (lasting for approximately 5-15 minutes). The research team also got all 23 participants to climb two flights of stairs on three separate occasions to equate to the energy expenditure during sex but none of them suffered any rhinitis following the task. The exact mechanism by which sex initiates and/or facilitates honeymoon rhinitis is not known. However, the authors speculated that emotional excitement and anxiety may be the trigger factors for post-sex rhinitis rather than exercise.

For most people, sneezing is just a common every day biological act. However, for some, a sneeze appears to be much more and something sexual. If you think sneezing fetishism is rare, just type “sneeze fetish” into Google and see what you get. There are loads of dedicated websites on sexual and sensual aspects of sneezing.

Here is one snippet I came across from a male (Greg, from Arlington, Virginia, USA):

“A gentleman with whom I have a mutual interest in companionship told me that he becomes sexually aroused when an attractive man sneezes. He said it makes no difference whether the sneeze is authentic or simulated. (He has never asked me to “fake” one for him; I told you, he’s a gentleman. And no, as fate would have it, my allergies have remained in check during the times we’ve been together, so I’ve not had occasion to observe his reaction firsthand.) My friend tells me that other folks, gay and straight, have this fetish”

Despite the many sites, I know of only one academic paper on sneezing fetishes. This was published over 20 years ago by Dr. Michael King in a 1990 issue of the journal Sexual and Marital Therapy. Dr. King reported the case of a 26-year-old homosexual male who was sexually aroused by observing other people sneeze and who also had an obsessive fear of vomiting in public. He was treated for his fear of vomiting with desensitization techniques, resulting in a rapid improvement in the man’s vomit phobia. Treatment was also attempted for the sneeze fetish through the use of covert sensitization. However, it had little effect on the man’s fetishistic impulses. Following this, he was taught to use thought-stopping techniques to reduce his preoccupation with fetishistic sneezing. I also came across a first person female account in a 2001 issue of The Straight Dope:

“I do know that my first love of sneezing came from the Smurfs. I doubt anyone else ever looked twice at a little blue sneezing midget (aptly named Allergic Smurf). Then, there was that scene in Disney’s Alice in Wonderland, the one where Alice is trapped inside White Rabbit’s house and has her nose tickled by smoke. I remember sitting entranced in front of the television set, watching that scene over and over and over again. As I grew older, I kept on watching out for sneezes on television shows. If I happened to see one, I would rush over to where the blank cassettes in our house lay and whip one out for the express purpose of taping the sneezes. [I married a man with] the most adorable stifled sneeze I’ve ever heard [and then divorced because] there was a hell of a lot more to making a relationship work than enjoying a great guy’s sneezing over the weekends”

After the break up of her marriage, this particular woman discovered a sneezing fetish site on the Internet, and fortuitously met a man with “photic sneeze reflex” (also known technically as ‘photoptarmosis’ but more colloquially called “sun sneezing” – comprising uncontrollable sneezing in response to numerous stimuli such as bright light). While sexual aspects associated with sneezing appear to be rare, there is more than anecdotal evidence suggesting that for a minority of people, this is not a subject to be sneezed at.

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

Further reading

Bhutta, M. F. & Maxwell, H. (2008). Sneezing induced by sexual ideation or orgasm: An under-reported phenomenon. Journal of the Royal Society of Medicine, 101, 587-591.

Foxhall, K. (2010). The Myth of “Seven Sneezes Equals an Orgasm”. February 7. Located at: http://kelly-foxhall.suite101.com/the-myth-of-7-sneezes-equals-an-orgasm-a198861

Gould, G.M. & Pyle, W.L. (1901). Anomalies and Curiosities of Medicine. London: W.B. Saunders.

King, M.B. (1990). Sneezing as a fetishistic stimulus. Sexual and Marital Therapy, 5, 69-72

Mackenzie, J. N. (1898). The physiological and pathological relations between the nose and sexual apparatus of man. Journal of Laryngology, Rhinology and Otology, 13, 109-123.

Monteseirin, J., Camacho, M.J., Bonilla, I., Sánchez-Hernández, C, Hernández, M. & Conde, J. (2001). Honeymoon rhinitis. Allergy, 56, 353-354.

Sex and gambling addictions: Is there a relationship?

From a psychological perspective it was Freud who made the first serious contribution to the psychology of gambling by claiming that gambling was a repetitious substitute for masturbation. He argued there were many parallels between the two behaviours including the importance of ‘play’, the exciting and frantic activity of the hands, the irresistibility of the urge, the intoxicating pleasure, the repeated resolutions to stop the activity, and the enormous feelings of guilt once the activity was completed. Freud also made reference to the privacy, solitude, manipulation, and specificity of the two activities. Other psychoanalysts claimed that gambling was analogous to foreplay, winning with orgasm, and losing with castration and defecation. Freud and his followers argued that gamblers had an “unconscious desire to lose” and that losing money was an act of masochistic self-punishment known as the “pleasure-pain tension”.

Believe it or not, Freud’s theories on the psychology of gambling stemmed from just one single case study – the Russian novelist Dostoyevsky. What’s more, Freud never even met him and based his ideas on the reading of Dostoyevsky’s semi-autobiographical novel The Gambler. As a psychologist rooted in the scientific method, I think Freud’s theories are little more than an amusing historical footnote. However, there are two aspects of Freud’s thinking that deserve further exploration. Firstly, Freud passionately believed that many of our motivations and desires are unconscious. Having spent many years asking gamblers why they do the things that they do, it becomes obvious that many gamblers can’t put into words their primary reasons for engaging in the activity they love so much. To me, there do appear to be inexplicable unconscious motivations. Secondly, there are many anecdotal observations on the relationship between gambling and sex.

Gambling lore holds that some heavy gamblers experience orgasm while being totally absorbed in the gambling experience. Whilst I have never come across such a case there are many examples of gamblers who make such comparisons. For instance, an infamous problem gambler known as ‘Charlie K’ claimed “every time I tapped out at a racetrack, it was just like a massive orgasm”. Actual orgasm during gambling is most probably a myth or unusual personal peculiarity although the ‘thrill’ and ‘high’ that many gamblers report while gambling, may be similar to the emotional arousal experienced during sex. On the other hand, it is perhaps worth noting that there are case studies in the psychological literature suggesting that one of the side effects of problem gambling may be impotence!

There is also the language of gambling. Psychoanalysts claim that the language used by gamblers gives clues to both the anal and genital sexuality of gambling. Dice playing is known as ‘craps’ and players use the phrases “to come” and “come-line”. The numbers ‘10’ and ‘4’ are known as “Big Dick” and “little Dick” respectively. The combined stakes are known as “the pot” and there are enema overtones in the phrase “to be cleaned out” when the gambler loses everything.  A show-off gambler is described as “cocky” or a “Posing Dick”. Furthermore, many card games bring sex to mind including ‘poker’ (male genitalia), ‘stud poker’ (intercourse) and ‘solo’ (masturbation). In addition, gamblers often express their feelings using sexual analogies. Gamblers often claim that they get the same kick out of gambling as they do about sex or comment on how they “would like to get a piece of Lady Luck”. Conversely, sex for the gambler can take on gambling overtones with men who “chase women” or try to “score with women”. Easy ‘pick-ups’ are referred to as “a safe bet” or “sure fire winner”.

There is very little in the way of anthropological research on sex and gambling. However, a number of psychologists and sociologists have made reference to the Mojave, a tribe where gambling involves strict sexual segregation. Here, women and male transvestites (called “lucky gamblers”), play a specialised gambling game called ‘Utoh’ that is steeped in sexual ritual. The game consists of four wooden dice painted red and black (symbolising boys and girls) which are thrown with the aim of landing them all with the same colour. To affect an opponent’s luck, players shout such phrases as “you have a big penis” and engage in activities such as “anus goosing” and “genitalia grabbing”. The Mojave also believe that sexual dreams bring good luck in gambling. Men of the tribe will go as far as wagering their own wives, who if husbands lose, become sexual mates of the winners

Although the case of the Mojave is interesting, it is clearly untypical of society at large. However, evolutionary psychologists claim that successful male gamblers should attract more attractive female sexual partners. The (somewhat) simplistic argument for this is that over time, males who have successfully gambled – that is, taken more risks – will have accumulated more resources and therefore (in evolutionary terms) be more attractive to females. This certainly seems to fit the James Bond Hollywood blockbuster image of a gambler. It is not uncommon to see such gamblers portrayed as ‘macho’, heroic, virile, and dominant. Unfortunately, such a theory has little validity in Western society as there are numerous less risky ways to accumulate wealth and resources.

Finally, there have also been a few studies (all based in North America) that have looked at the comorbid relationships between gambling addiction and sex addiction. Back in 1991, Henry Lesieur and Richard Rosenthal reported two conference papers of small samples of adult gambling addicts in which 12% and 14% were potentially sexually addicted. In a bigger (and much more recent) study by Jon Grant and Marvin Steinberg, one on five (19.6%) met the criteria for sexual addiction among their 225 adult pathological gamblers. Otto Kausch reported that among 94 adult gambling addicts, just below a third (31%) suffered from sexual addiction. Patrick Carnes and colleagues reported that among a sample of 1,604 adult residential treatment sex addicts, 6% reported addiction to gambling, Obviously there are major methodological shortcomings of all these studies particularly because they include small, non-representative, and self-selected samples. However, they do suggest that there may be some relationship between addictive gambling and addictive sex for some people.

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

Further reading

Carnes, P.J., Murray, R.E., & Charpentier, L. (2005). Bargains with chaos: Sex addicts and addiction interaction disorder. Sexual Addiction & Compulsivity, 12, 79-120.

Freud, S. (1928). Dostoyevsky and parracide. In J. Strachey (Ed.). The standard edition of the complete psychological works of Sigmund Freud. Hogarth Press: London.

Grant, J.E., Steinberg, M.A. (2005). Compulsive sexual behavior and pathological gambling. Sexual Addiction & Compulsivity, 12, 235-244.

Kausch, O. (2003). Patterns of substance abuse among treatment-seeking pathological gamblers. Journal of Substance Abuse Treatment, 25, 263-270.

Lesieur, H.R., & Rosenthal, R. J. (1991). Pathological gambling: A review of the literature (Prepared for the American Psychiatric Association Task Force on DSM-IV Committee on Disorders of Impulse Control Not Elsewhere Classified). Journal of Gambling Studies, 7, 5-39.

Sussman, S., Lisha, N. & Griffiths, M.D. (2011). Prevalence of the addictions: A problem of the majority or the minority? Evaluation and the Health Professions, 34, 3-56.