A headache following ejaculation or orgasm is medically termed Primary Headache Associated with Sexual Activity (PHASA). This phenomenon, once commonly known as benign coital cephalgia, affects a small percentage of the population and is reported to be more frequent in men than in women. While the pain is often intense, the underlying cause is typically benign, meaning it is not related to a serious underlying condition. Understanding the causes, which are largely rooted in the body’s normal physiological response to sexual excitement, helps demystify this recurrent issue.
The Two Types of Sex-Related Headaches
PHASA can manifest in two distinct ways, traditionally categorized by the timing and nature of the pain. The first type is the pre-orgasmic headache, which develops gradually as sexual excitement increases. This pain is often described as a dull, bilateral ache that feels like a tension headache, frequently localized in the head and neck. It is thought to be related to the sustained muscular contraction that occurs during the excitement phase of sexual activity.
The second and more commonly reported type is the orgasmic headache, which is characterized by a sudden, severe, and explosive pain that peaks precisely at the moment of climax. This headache presents as a “thunderclap” of pain, reaching its maximum intensity almost instantaneously. The location of this explosive pain can be generalized across the head or concentrated in the occipital region. Although the International Headache Society now classifies PHASA as a single entity with a variable presentation, distinguishing between these two patterns remains useful for understanding the patient’s experience. Both types can last from a few minutes up to several hours, and in milder cases, the headache may persist for up to three days.
Physiological Mechanisms Behind Benign Headaches
The benign forms of PHASA are linked to the significant changes in the body’s circulatory system during sexual excitement. Sexual activity is a form of exertion that leads to a rapid and pronounced increase in heart rate and blood pressure, comparable to moderate-intensity exercise. During the final stage of climax, a person’s systolic blood pressure can spike substantially, sometimes rising to 160-170 mmHg or higher.
This rapid elevation in systemic blood pressure is thought to affect the blood flow dynamics within the brain’s vascular system. The pain may arise from the sudden dilation of cerebral blood vessels in response to the pressure surge, a process known as impaired cerebrovascular autoregulation. This sudden change in vessel diameter can activate pain-sensitive nerve fibers surrounding the brain’s arteries.
Another significant mechanism is the Valsalva maneuver, which involves forceful exhalation against a closed airway, a natural occurrence during the straining of orgasm. This action momentarily increases pressure within the chest and abdomen, which translates to a temporary increase in intracranial pressure. This pressure change, combined with the muscular tension in the neck and jaw, can trigger the pain signals associated with the headache. The pre-orgasmic headache, in particular, has a strong muscular component, where sustained tension in the muscles of the head and neck contributes to the dull, aching pain.
Warning Signs and Secondary Causes
While most sex-related headaches are benign, any new onset of a severe headache during sexual activity must be evaluated immediately to rule out a Secondary Sex Headache. These secondary headaches are caused by underlying pathological conditions and can be life-threatening. The most concerning presentation is an explosive, thunderclap headache that is described as the “worst headache of one’s life,” especially when it occurs for the first time.
Red flag symptoms that necessitate immediate medical attention include the headache being accompanied by neck stiffness, vomiting, loss of consciousness, or any focal neurological symptoms like weakness or vision changes. These symptoms may point toward a dangerous event, such as a Subarachnoid Hemorrhage (SAH). SAH is bleeding around the brain that can be precipitated by the sudden blood pressure spike of orgasm.
Other serious secondary causes include Reversible Cerebral Vasoconstriction Syndrome (RCVS), where blood vessels in the brain temporarily narrow, and intracranial aneurysms. A spontaneous Cerebrospinal Fluid (CSF) leak is another distinct secondary cause, which can be triggered by the physical stress of coitus. A CSF leak often causes a headache that is postural, meaning the pain worsens when standing up and significantly improves when lying down, a pattern that is different from benign PHASA.
Diagnosis and Treatment Options
The first step in addressing a sex-related headache is to seek medical consultation, allowing a physician to differentiate between the benign primary form and a potentially dangerous secondary cause. The diagnosis of PHASA is ultimately one of exclusion, meaning the doctor must first rule out structural issues using neuroimaging. This typically involves a computed tomography (CT) scan or magnetic resonance imaging (MRI) of the brain and its blood vessels.
If the neuroimaging results are clear and no underlying pathology is found, the headache is diagnosed as benign PHASA. For individuals who experience frequent attacks, a physician may recommend a preemptive pharmacological approach. The most effective treatment is often a non-steroidal anti-inflammatory drug (NSAID) like indomethacin, taken 30 to 60 minutes before sexual activity. A typical preemptive dose is 25 to 50 milligrams.
For people who experience attacks frequently, a daily prophylactic medication may be more appropriate. Beta-blockers, such as propranolol, are often prescribed to help stabilize blood pressure and heart rate, which reduces the physiological trigger for the headache. Non-pharmacological strategies include recognizing the onset of the dull, pre-orgasmic pain and ceasing sexual activity before climax, or trying different sexual positions to minimize neck and muscle strain.