Sexual Activity and Mysterious Headaches

Do you get mysterious headaches with sexual activity? May be not. But for one reader of my columns this has become a significant problem.

It is estimated that patients who have headache with sexual activity account for approximately one per cent of all headache patients. It is likely that the prevalence of this headache is underestimated, since patients often feel embarrassed to report intimate details about their sexual activities.

This condition has been given many names: benign coital headache (most of the time no serious underlying cause is found), masturbatory headache, orgasmic cephalagia (as it occurs usually at or near orgasm).

Apparently, headache related to sexual activity has been recognized since the time of Hippocrates. But the first systematic descriptions of this condition appeared in medical literature in 1974. Since then primary headache associated with sexual activity has become a well defined entity.

Coital headache is usually a recurrent, benign headache and is more common in men than in women. It can occur just before, during, or immediately after orgasm. The headaches are usually dull and throbbing and last from minutes to hours. Occasionally, some patients experience a sudden, explosive headache that occurs during orgasm.

Three types of sexual headaches are recognized.

The first, the dull type, is described as a dull ache in the head and neck that intensifies as sexual excitement increases, peaking at orgasm. This type of headache is little less common than type two.

Type two, also known as vascular or explosive coital headache, is a sudden, severe, explosive headache that occurs just before or at orgasm and persists for a few minutes to 48 hours. This is the most common type of coital headache. Patients find orgasmic headache frightening, distressing and disabling.

Type three is a postural headache, resembling that of low cerebro- spinal fluid pressure that develops after coitus. This type of headache is rare.

When patients first present with coital or orgasmic headache, it is mandatory to exclude serious underlying condition like ruptured aneurysm and bleeding in the brain. When a patient presents with a new type two coital headache of sudden onset, a CT scan should be performed, and even if this is negative, a lumbar puncture should be obtained, says one research paper.

Aneurysm without rupture can present as coital headache. To pick this condition it is necessary to do an angiography and MRI of the cerebral blood vessels. Other cause for coital headache is central nervous system vasculitis.

During the acute phase of pain, usual analgesics (ibuprofen, diclofenac, acetaminophen, ASA) can be tried but are considered of limited value to relieve the pain. In 25 per cent of the patients the pain may last more than two hours and up to 24 hours. Other medications which have been tried with some success are triptans, propranolol and indomethacin.

Fortunately, the prognosis is good and in the majority of patients where no underlying pathology is identified. With time the headaches disappear without any specific treatment.

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Abdominal Aortic Aneurysm Is A Ticking Time Bomb

I recently saw an ad put out by the Canadian Society of Vascular Surgeons (CSVS) calling for a national screening program for abdominal aortic aneurysm (AAA). AAA has been described as a ticking time bomb.

Now, not everybody knows where this ticking time bomb is sitting in our body. Please do not rush for a total body scan to look for this bomb and do not ask, “Doc, which wire should I pull to defuse the bomb, red or blue?” Just kidding.

Let me explain and dissect the three words: abdominal aortic aneurysm. As most of you know, abdomen is a space between the diaphragm and the pelvis. Aorta is the largest vessel in the body and runs from the heart to the pelvis. That means a segment of it passes through the abdomen. Word aneurysm is derived from Greek word aneurusma, which means to dilate. So, aneurysm is a sac like widening of an artery resulting from weakening of the artery wall.

The normal aortic width is approximately two centimeters in men and a bit smaller in women. As the aorta increases in size, the risk of rupture increases. The gradual increase in the size of the aorta occurs over several years and does not produce any symptoms. But when it ruptures and leaks the patient will develop pain in the abdomen. The clinical diagnosis is not easy but the rupture can be diagnosed with a CAT scan. Emergency surgery after a rupture does not always have a good outcome. The majority of the patients do not survive.

If AAA is detected early then elective surgery has a better outcome. Five per cent of men and under one per cent of women over the age of 65 have an AAA. It is the 10th leading cause of death in Canadian men older than age 65. Studies from the United Kingdom have shown screening programs for early detection and treatment of AAA are cost-effective and save lives.

CSVS makes the following recommendation:

-National and provincial health ministries develop a comprehensive population-based ultrasound screening program for AAA detection and referral.
-All men aged age 65-75 be screened for AAA
-Individual selective screening for those at high risk for AAA. For example: women over age 65 at high risk secondary to smoking, cerebro-vascular disease and family history of AAA and men less than 65 with positive family history.

What is required for screening? AAA can be visualized by just using simple ultrasound scan of the abdomen limited to visualization of the abdominal aorta. CSVS has reviewed data that demonstrated screening men 65 to 75 will reduce aneurysm related death by half and at seven year follow-up a benefit on all cause mortality was noted.

The data also shows three aneurysms discovered by screening and repaired electively, will prevent one aneurysm death. For men, the number needed to screen to prevent one AAA mortality is similar to mammography.

What about women? CSVS says the incidence of AAA in women is significantly less and population based screening in all women has not been shown to reduce mortality. Selective screening of women is recommended as discussed earlier.

In an interview in the Medical Post, Dr. Thomas Lindsay, a vascular surgeon and a spokesman for the CSVS says that elective surgical repair of AAA is considered when the aneurysm reaches a diameter of 5.5 cm. at which point the annual risk of rupture is in the neighborhood of 10 per cent. Persons with an enlarged aorta that hasn’t yet reached that diameter would need repeat ultrasound screenings every six months to two years.

About 1,000 Canadians suffer ruptured aortic aneurysms every year and most people die as a result. But doctors say they could cut that number in half with ultrasound screening programs.

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