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Primary headache associated with sexual activity.pptx
- 1. Primary headache associated withsexual activity Done by Abdulghani Jaafar
- 2. INTRODUCTION Headache associated withsexual activity is one of the uncommon headache syndromes that occurs in t h e s e t t i n g o f a s p e c i f i c triggers.onset may be gradual during sexual activity or sudden at t h e t i m e o f o r g a s m .
- 3. Other term Sexual headache Benignvascular sexual headache Coital/intercourse cephalalgia/Headache Pre-orgasmic or orgasmic cephalalgia/Headache
- 4. PATHOPHYSIOLOGY The causesof are unknown, and the proposed mechanisms are largely speculative. are difficult to study because of their relative rarity and variable pre-orgasmic and orgasmic clinical presentations. Pre-orgasmic headaches have : proposed to arise from excessive contraction of neck and jaw muscles during sexual activity and might be avoided by conscious relaxation of these muscles during intercourse .
- 5. Follow:PATHOPHYSIOLOGY Orgasmic headaches: attributed to rapid increases in blood pressure and heart rate that occur during orgasm . Trigeminovascular activation may cause vasodilation due to release of inflammatory neuropeptides, leading to cerebrovascular dysregulation and head pain, similar to proposed mechanisms in migraine [
- 6. Epidemiology Primary headacheassociated with sexual activity is rare, but its exact prevalence and incidence is unknown. The male to female ratio approximately 3:1 The mean age of onset is 37 to 39 years but can present at any sexually active age .Other primary headache syndromes are common in patients with sexual headache, migraine (25 percent), exertional headache (29 percent), and tension-type headache (45 percent).
- 7. Clinical features The onsetof headache with sexual activity characterizes the syndrome. Symptoms may occur with sexual intercourse or masturbation and may recur with subsequent sexual activity .
- 8. - Head pain bilateral in approximately two-thirds of patients and unilateral in one-third . typically occipital or diffuse. . pressure-like or throbbing and can vary in peak intensity from mild to severe. .Severe symptoms are often brief, lasting several minutes in most patients, but a milder headache may persist for 24 up to 72 hours.
- 9. Clinical variability hastraditionally been divided into two types, pre-orgasmic and orgasmic, each with somewhat distinct clinical features:
- 10. Pre-orgasmic headache This"dull type" typically features pressure-like or aching pain .that appears during sexual activity and gradually increases with mounting sexual excitement . Patients may note increased contraction in neck and jaw muscles along with the headache. Symptoms are often very brief. persisted for about 30 minutes on average with a range from 1 to 180 minutes. 30% of the primary headaches associated with sexual activity .
- 11. Orgasmic headache "explosivetype," characterized by a sudden onset of severe head pain occurs just prior to or at the moment of orgasm and followed by severe throbbing head pain. may generalize rapidly to involve the entire head. The severe pain often lasts for <15 minutes, but the subsequent throbbing head pain often persists for several hours . 70 percent of primary headache associated with sexual activity . Note:Sexual headaches may be unpredictable and are not necessarily precipitated with every sexual encounter .
- 12. Associated symptoms Severeheadaches associated with sexual activity may be associated with nausea and vomiting..Cranial autonomic symptoms do not typically occur with the headache.
- 13. Evaluation and diagnosis . suspected when characteristic headache symptoms occur during sexual activity. . requires the exclusion of subarachnoid hemorrhage (SAH) and other secondary causes.
- 14. Diagnostic criteria Thediagnostic criteria from the International Classification of Headache Disorders, 3rd edition (ICHD-3) are as follows : (A) At least two episodes of pain in the head and/or neck fulfilling all the criteria below (B) Brought on by and occurring only during sexual activity ● (C) Either or both of the following:Increasing in intensity with increasing sexual excitementAbrupt explosive intensity just before or with orgasm (D) Lasting from 1 minute to 24 hours with severe intensity and/or up to 72 hours with mild intensity (E) Not better accounted for by another ICHD-3 diagnosis
- 15. Probable diagnoses thereis only one episode fulfilling criteria B through D or if there are at least two headaches fulfilling criterion B and either (but not both) of criteria C and D
- 16. Approach Patients reportingsudden-onset severe symptoms, including those with orgasmic onset of symptoms, should be evaluated urgently SAH and other acute conditions that may present with thunderclap headache . Once urgent evaluation excludes SAH, further evaluation to exclude other secondary causes is warranted for patients with orgasmic headache symptoms and for all patients with new-onset pre-orgasmic headache symptoms.
- 17. Evaluation for subarachnoidhemorrhage for patients with orgasmic headache symptoms — Orgasmic headache is particularly worrisome because of its similarity to theheadache of SAH, and because 4 to 12 percent of patients presenting with SAH due to an aneurysmal rupture cite sexual intercourse as the precipitating event. The workup to exclude SAH typically includes: Head computed tomography (CT) to identify acute bleeding Lumbar puncture (LP) to identify xanthochromia in cerebrospinal fluid (CSF) Additional testing if initial testing is nondiagnostic (eg, blood in CSF attributed to traumatic LP) or delayed (eg, >2 weeks from symptom onset). After SAH has been excluded, if initial testing has not identified an alternative structural cause to symptoms, further testing to exclude other structural causes is warranted.
- 18. Evaluation for othersecondary causes for all patients For patients with orgasmic headache symptoms not attributed to SAH and for patients presenting with new- onset preorgasmic, dull headache symptoms, we suggest evaluation to exclude secondary causes. Patients who present pre-orgasmic headache symptoms, a chronic history of multiple similar prior episodes consistent with primary headache associated with sexual activity, and a normal examination may not require additional diagnostic evaluation.
- 19. Secondary causes ofsexual headache include: -reversible cerebral vasoconstriction syndrome intracerebral hemorrhage, - reversible posterior leukoencephalopathy syndrome -cervical artery dissection - cerebral venous thrombosis -and cardiac ischemia.
- 20. Testing to excludesecondary causes CT- or MR-angiogram of head and neck MRI brain and MR venogram with gadolinium contrast Blood and urine toxicology screen Electrocardiogram Note-A benign (ie, primary) sexual headache syndrome is likely if no abnormality is identified despite a thorough evaluation for structural, vascular, or pharmacologic causes.
- 21. DIFFERENTIAL DIAGNOSIS Subarachnoidhemorrhage Reversible cerebral vasoconstriction syndrome Intracerebral hemorrhage . Reversible posterior leukoencephalopathy syndrome . Ischemic stroke . Cerebral and cervical (carotid or vertebral) arterial dissection . Cerebral venous thrombosis . Spontaneous intracranial hypotension . Meningitis and encephalitis . Pheochromocytoma . Cardiac ischemia .
- 22. Treatment Acute symptomatictreatment — -triptans first choice as: •Zolmitriptan 5 mg intranasal spray •Sumatriptan 3 mg, 4 mg, or 6 mg subcutaneous injection- -Alternative: •Naproxen 500 mg per os (PO; orally) •Ketorolac 30 mg intravenous (IV) or 60 mg intramuscular (IM) •Metoclopramide 10 mg IV •Prochlorperazine 10 mg IV or IM
- 23. Treatment Preventive treatment— Anticipatory pretreatment options – taken typically 30 to 60 minutes before sexual activity. Dosing and initial options include: ●Indomethacin 25 mg orally, titrated to effect up to 150 mg ●Propranolol 40 mg orally, titrated to effect up to 200 mg ●Sumatriptan 6 mg subcutaneous injection Daily medications – For patients who take daily preventive therapy, we typically start at a low initial dose, increasing gradually to effect and tolerance. Dosing and initial options include: ●Indomethacin 25 mg orally once daily, up to maximum dose of 225 mg orally once daily ●Propranolol 40 mg orally once daily, up to maximum dose of 240 mg orally once daily ●Also some triptans can get some benefits
- 24.