Unusual Headache Disorders

Primary Headache Associated with Sexual Activity: A Review of the Literature

PURPOSE OF REVIEW

This review summarizes the evolution in diagnosis, evaluation, and treatment of primary headache associated with sexual activity (PHASA).

RECENT FINDINGS

Despite increased access to patient information and advances in imaging, the pathophysiology of PHASA remains not fully understood. There are many secondary headaches that may present with headache during sexual activity, and a thorough workup is indicated to rule out potentially life-threatening etiologies. Many recent case series discuss the efficacy of known treatments of PHASA, as well as suggest other potential therapies for this condition including the newer CGRP-targeted therapies. Headaches during sexual activity can be worrisome events which necessitate urgent evaluation, particularly when presenting with sudden-onset and severe "thunderclap" headaches. A thorough workup including imaging should be conducted to rule out etiologies such as subarachnoid hemorrhage, reversible cerebral vasoconstrictive syndrome (RCVS), vasospasm, and dissection. PHASA is commonly comorbid with migraine, tension-type headache, exertional headache, and hypertension. PHASA can present as a dull headache that progresses with sexual excitement, or an explosive headache at or around orgasm. Pain is primarily occipital, diffuse, and bilateral. The headaches are discrete, recurrent events with bouts that typically self-resolve, but may also relapse and remit or continue chronically in some patients. PHASA can be treated preemptively with indomethacin and triptans administered prior to sexual activity, or treated prophylactically with beta-blockers, topiramate, and calcium channel blockers. CGRP-targeted therapies may provide relief in PHASA based on a few case reports, but there are no randomized controlled trials looking at specific efficacy for these therapies.

Cold Stimulus Headache

PURPOSE OF REVIEW

To provide an updated review on cold stimulus headache.

RECENT FINDINGS

Age, type of stimulus, comorbidities, and study design but not necessarily gender appear to influence the reported prevalence of cold stimulus headache (CSH). Different cold stimuli appear to provoke different types of CSH. Ice water appears to provoke more frequent and higher pain intensity with a shorter latency compared to CSH provoked by ice cubes. Cold stimulus headache is very common unusual headache with limited literature. The severity, frequency, and latency appear to be influenced by the speed and size of the exposed area.