Honey..... STOP!! I have a headache

A case that was briefly discussed in our Neurology morning report...presented by Dr.Dadu .
A 30 yo female with h/o tension headache, presented to ER with 2 episodes of headache(different than her tension headache) during sex with her boyfriend(of long time).each time it lasted for 2 hours. not associated with nausea or vomitting. Physical exam did not reveal any abnormality. Should this lady be investigated ?
Lets see....
Headache associated with sexual activity-HSA (also..orgasmic headache, beningn sexual headache, coital headache) as termed by ICHD -II, has been described as bilateral and occipital lasting anywhere between 10min to 6 hours. More common in men than women (4:1). Comorbidity with other headaches(migraine, tension etc) is common. It can be further divided into
 Preorgasmic Headache - A) Dull ache in the head and neck associated with awareness of neck and/or jaw muscle contraction and B) Occurs during sexual activity and increases with sexual excitement
C) Not attributed to another disorder
Orgasmic Headache - A) Sudden severe (‘explosive’) headache B) Occurs at orgasm
C) Not attributed to another disorder

Orgasmic headache is considered to be mostly of vascular origin.In a study done with trans cranial doppler in pts with orgasmic headache showed impaired cerebral autoregulation leading to reversible vasoconstriction. (1976) . Indomethacin seems a good treatment option...with propranolol being a good prophylactic.

But what shall we do for our patient while she is in the emergency room. Have a look at this study from Spain where they looked at 6500 pts with headache. Of these 18 pts had HSA. All patients with HSA had CT head and followed by lumbar puncture if needed. This diagnosed 2 of the 18 patients with Sub arachnoid hemorrhage. Based on this ..and some other studies..the incidence of HSA is around 1%. Of the pts presenting with HSA, sub arachnoid hemorrhage(SAH) or a aneurysm may be an underlying diagnosis in upto 10%. The rest are all benign sexual headache.
Given the risk of high mortality & successful treatment with SAH........even if the prevalence is low..it will be reasonable to image them on first presentation with CT head ..followed by lumbar puncture if needed. So our lady had these investigations..and they were negative.She has benign HSA.