Headaches during sexual activity require careful clinical evaluations. Speaking at the French Language Neurology Days 2026, Anne Ducros, MD, PhD, professor of neurology at the University of Montpellier and director of the Headache Centre at Montpellier University Hospital, Montpellier, France, said, “The occurrence of headaches related to sexual activity, during orgasmic or pre-orgasmic phase, is a phenomenon that can be very concerning, sometimes justifying calling emergency services, but it can also be benign, depending on the case.” 

Clinicians should first exclude secondary causes. “It is important to exclude vascular causes, such as subarachnoid hemorrhage and reversible cerebral vasoconstriction syndrome (RCVS) when evaluating headache related to sexual activity, whether orgasmic or pre-orgasmic. In some cases, signs of intracranial hypertension or other nonvascular causes may also be responsible,” Ducros said.

Clinical Features

Primary headache associated with sexual activity has been described since the 1970s under various terms. It typically presents as bilateral posterior pain that intensifies with arousal and becomes severe during an orgasm. The classification was updated in 2018, and diagnosis requires the absence of any intracranial condition.

According to a Danish study, the condition is rare, with a prevalence of about 1%, similar to cough or exertional headaches. It affects men more often than women, with a ratio of 3:1, and most cases occur between the ages 37-44, consistent with other exertional headache syndromes.

Diagnostic Criteria

Diagnosis relies on exclusion. “The diagnosis must be made by exclusion. Criteria include at least two episodes of headache or neck pain occurring only during sexual activity, either with gradual increase during arousal or sudden onset at orgasm,” Ducros stated.

The duration of pain ranges from 1 minute to 24 hours for severe episodes and up to 72 hours for milder forms, with no alternative explanation for symptoms.

The clinical presentation varies. Headaches may occur during intercourse, masturbation, or sexual arousal alone, including during the viewing of pornography or erotic dreams.

“The diagnosis of RCVS is based on clinical and radiologic assessment. Vasoconstriction is usually demonstrated by noninvasive angiography, although it may be absent during the first week or may not appear on repeated imaging,” Ducros said.

RCVS is the most common cause of sudden recurrent headaches and headaches associated with sexual activity. Since 2018, the criteria have defined probable RCVS in patients with normal cerebral angiography who have experienced 2 or more episodes of thunderclap headache, including at least one episode triggered by a specific activity.

Sexual activity is the most common trigger, followed by exertion, emotional stress, showering, bathing, or forward bending. In patients who present with 2 or more episodes of headache related to sexual activity within 1 week and have a normal diagnostic workup, RCVS should be considered.

Treatment Approach

“The proposed treatment is similar to that used for exertional or cough headache: beta-blockers or indomethacin. It is important to advise patients who have experienced RCVS to modify their sexual activity and maintain steady breathing. For those with occasional symptoms, indomethacin may be taken before activity” Ducros said.

“Forty percent of individuals can stop their headache by interrupting intercourse, and 51% can reduce it by adopting a passive position,” she noted.

“In summary, when sudden-onset sexual headaches occur, tests should be performed promptly to exclude subarachnoid hemorrhage. Explosive and recurrent sexual headaches suggest RCVS or probable RCVS. Primary headache related to sexual activity remains a diagnosis of exclusion, especially in men, and is often associated with exertional headache, with episodic or chronic patterns,” she concluded.

This story was translated from Univadis France, part of the Medscape Professional Network.