4.3 Primary headache associated with sexual activity

Previously used terms:

Benign sex headache; benign vascular sexual headache; coital cephalalgia; coital headache; intercourse headache; orgasmic cephalalgia; orgasmic headache; sexual headache.

Coded elsewhere:

Postural headache occurring after coitus should be coded as 7.2.3 Headache attributed to spontaneous intracranial hypotension because it is most probably due to CSF leakage.


Headache precipitated by sexual activity, usually starting as a dull bilateral ache as sexual excitement increases and suddenly becoming intense at orgasm, in the absence of any intracranial disorder.

Diagnostic criteria:
  1. At least two episodes of pain in the head and/or neck fulfilling criteria B-D
  2. Brought on by and occurring only during sexual activity
  3. Either or both of the following:
    1. increasing in intensity with increasing sexual excitement
    2. abrupt explosive intensity just before or with orgasm
  4. Lasting from 1 minute to 24 hours with severe intensity and/or up to 72 hours with mild intensity
  5. Not better accounted for by another ICHD-3 diagnosis1;2.
  1. 4.3 Primary headache associated with sexual activity is not associated with disturbance of consciousness, vomiting or visual, sensory or motor symptoms, whereas symptomatic sexual headache may be. On the first onset of headache with sexual activity, it is mandatory to exclude subarachnoid haemorrhage, intra- and extracranial arterial dissection and reversible cerebral vasoconstriction syndrome (RCVS).
  2. Multiple explosive headaches during sexual activities should be considered as 6.7.3 Headache attributed to reversible cerebral vasoconstriction syndrome (qv) until proven otherwise by angiographic studies (including conventional, magnetic resonance or computed tomography angiography) or transcranial Doppler ultrasonography. Of note, vasoconstrictions may not be observed in the early stage of RCVS; therefore, follow-up studies may be needed.

Two subtypes (preorgasmic headache and orgasmic headache) were included in ICHD-I and ICHD-II, but clinical studies have since been unable to distinguish these; therefore, 4.3 Primary headache associated with sexual activity is now regarded as a single entity with variable presentation.

Recent studies have shown that up to 40% of all cases run a chronic course over more than a year.

Some patients experience only one attack of 4.3 Primary headache associated with sexual activity during their lives; they should be diagnosed as 4.3.1 Probable primary headache associated with sexual activity. For further research on this headache type, it is recommended to include only patients with at least two attacks.

Epidemiological research has further shown that 4.3 Primary headache associated with sexual activity can occur at any sexually active age, is more prevalent in males than in females (ratios range from 1.2:1 to 3:1), occurs independently of the type of sexual activity, is not accompanied by autonomic or vegetative symptoms in most cases, is bilateral in two-thirds and unilateral in one-third of cases and is diffuse or occipitally localized in 80% of cases. Attack frequency of 4.3 Primary headache associated with sexual activity should always be related to the frequency of sexual activity.