Post coital headaches: a question and an answer

One of the readers of my blog asked me an interesting question about post coital headaches.  I am reproducing his question here. My reply to it follows:


Recently I too began having pre and post-coital headaches. The first time it happened I was obviously very concerned, so I scheduled an appointment with a doctor who recommended an MRI with and without contrast.

Fortunately, for me the MRI turned up normal, however, I still have the pain and the intensity varies. Occasionally, the pain occurs during arousal although it is not intense. Sometimes there is no pain. Sometimes the pain still occurs days after sex, more as a low throbbing though.

Although perhaps unrelated, years ago I was diagnosed as having a low testosterone level. Nothing that warranted medication, but it was on the low side. A doctor suggested I might want to consider medication since we were trying to conceive and had some difficulty with the second child, but we were successful without it.

My question for the doc is can these types of headaches be associated with low T? Furthermore, should I be concerned that the headaches are a result of a more serious condition, such as a heart condition? Although I am not on medication for high-blood pressure, I noticed the other day at the doctor’s that my blood pressure was 137/75. To me, this seems high for my body. In my 20′s my BP typically ran 100-110/60-65. I am 42 yrs old now.

Should I be put on ow T / BP meds and develop a more regular exercise and diet plan?



Dear B,

                   You ask an interesting question. As I stated in my post on post coital headaches, usually the headache comes on suddenly either at the height of coitus (at the time of orgasm) or soon there after. Patients may use various terms to describe the headache. The headache usually is of a moderate to severe intensity and at times is referred to as a thunderclap headache (basically any headache which on suddenly and is of a severe intensity can be referred to as a thunderclap headache. So a severe sudden attack of migraine can be a thunderclap headache too). Some people may have noticed the temporal attention of the headache to coitus over time and hence do not seek medical attention. It is usually people who have never suffered a post coital headache (or rather I should say who do not suffer from headaches usually) that get sufficiency alarmed and seek medical attention. Now what do I as a physician neurologist or the ER physician who examines you think when you present with a thunderclap headache? Well the think you are most worried about is whether the patient’s severe sudden headache may be on account of something more sinister such as hemorrhage into the brain. There are various causes of hemorrhage (bleeding) into the brain. They can broadly be divided into:

  1. Traumatic (as the name says it, the hemorrhage is on account of head trauma)
  2. Non-traumatic (examples of non-traumatic hemorrhage include: hypertensive intracerebral hemorrhage—the hemorrhage is on account of high blood pressure and non-traumatic subarachnoid hemorrhage (SAH) among various others. Non-traumatic subarachnoid hemorrhage is a special type of hemorrhage and usually occurs in the setting of either a rupture of an intracranial aneurysm or sudden bleeding from a vascular malformation in the brain such as an anteriovenous malformation. As you may well imagine if an aneurysm was to suddenly rupture in the brain, the headache is invariably sudden and of a severe intensity. This the headache can mimic a post coital headache in character. Moreover the headache comes on in the setting of severe exertion and thus further raises concern

So if you present to the ER in this setting, we as physicians want to rule out a subarachnoid bleed. The easiest way to do this is with the aid of a plain (no contrast is used) head CT scan.  The non-contrast head CT is extremely sensitive in ruling out hemorrhage. If you see blood on the CT scan then you treat the patient accordingly (in this post I shall not dwell over the treatment of intracranial and subarachnoid hemorrhage). The problem actually arises if the CT scan comes back negative (meaning no blood is seen). Now in this setting the physician may (after taking a detailed history) just simply reassure you that this is post coital headache (since it occurred in the setting of an orgasm) and there is no reason to be alarmed. If on the other hand the history is atypical or there are other points which raise a red flag (example the patient’s blood pressure is high or he has a prior history of subarachnoid hemorrhage or he has a history of intracranial aneurysm or other vascular malformation), the physician may opt to do other tests. Sometimes after the rupture of an intracranial  aneurysm, no gross blood is seen (meaning the hemorrhage is very small in quantity). In those settings we do a spinal tap (lumbar puncture) to see if there is any blood in the spinal fluid. As you may be aware of, the spinal fluid is usually clear and colorless (it does not have any blood in it). In the setting of a subarachnoid hemorrhage, blood is found in the spinal fluid (xanthochromia in CSF) thus confirming the diagnosis of a subarachnoid bleed. In this setting further tests may be carried out such as a MRI of the brain and a MRA (magnetic resonance angiography) to better visualize the aneurysm or the vascular malformation in the brain. Sometimes a formal angiogram is carried out.

So in reply to your question B, to my knowledge there is no direct correlation between low testosterone levels and post coital headaches. My advise to you would be as follows. Bring the blood pressure to the attention of your Internist. Usually doctors have patients keep a blood pressure diary (meaning they have you chart your blood pressure about a week or two). This helps in determining if you indeed suffer from hypertension or not (as you can imagine a single solitary reading is not sufficient to make this determination). Depending your cardiovascular risk factors (history of smoking, high cholesterol and so forth), your doctor may opt to do more tests to rule out any underlying heart condition.

Regular exercise and dietary modification are seldom ill advised. My advise though would be to run it past your doctor before you embark on a exercise or a dietary modification plan.

Personal Regards,

Nitin Sethi, MD