Primary Headache Associated with Sexual Activity (PHASA)

1. PRIMARY HEADACHE
ASSOCIATED WITH SEXUAL ACTIVITY (PHASA)
ADE WIJAYA, MD – FEBRUARY 2020

2. OUTLINE:
 Definition
 Clinical presentation
 Diagnosis
 Management
 Summary

3. DEFINITION
The presence of > 2 episodes of pain in the head or neck, brought on by and occurring only during sexual
activity, either increasing during sexual excitement or starting abruptly and intensely before or at the time
of orgasm, lasting from 1 minute to 72 hours and not being accounted for by another ICHD-3 diagnosis
Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, (beta version). Cephalalgia. 2013 Jul;33(9):629-808.

4. CLINICAL PRESENTATION
 A dull pain, predominantly bilateral (two-thirds bilateral and one-third unilateral), diffuse or occipital in
80% of cases, that increases with sexual excitement and may suddenly become severe immediately
before, at, or after orgasm.
 Pain duration in each episode is variable and can last from 1 minute to 72 hours, with a median severe
pain duration of 30 minutes.
 The presentation is usually in bouts, with periods of months (mean 3 ± 5 months) between attacks
despite sexual activity occurring.
 Up to 40% of cases assume a more chronic course over periods of >1 year.
 Studies consistently show a male preponderance with up to a 4-fold rate among men.
 In regard to age, PHASA has 2 peaks of prevalence, the first between 20 and 24 years and the second
between 35 and 44 years
Nascimento, B., & Mulhall, J. P. (2018). Sexual Headache.

5. DIAGNOSIS
DIAGNOSIS OF EXCLUSION
Differential diagnosis:
Subarachnoid hemorrhage (SAH)
Severe hypertensive crisis (blood pressure >180/ 120)
Cerebral arterial dissection
Reversible cerebral vasoconstriction syndrome
Intracerebral hemorrhage
Increased intracranial pressure
Neoplasm
Cerebral venous thrombosis
Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, (beta version). Cephalalgia. 2013 Jul;33(9):629-808.
Turner IM, Harding TM. Headache and sexual activity: A review. Headache 2008;48:1254-1256.

6. Nascimento, B., & Mulhall, J. P. (2018). Sexual Headache.

7. MANAGEMENT
 Acute treatment
 Preemptive treatment
 Prophylactic treatment
Nascimento, B., & Mulhall, J. P. (2018). Sexual Headache.

8. ACUTE TREATMENT
 Indomethacin 25-50 mg
 Triptans 50-100 mg
Frese A, Rahmann A, Gregor N, et al. Headache associated with sexual activity: Prognosis and treatment options. Cephalalgia 2007;27:1265.
Frese A, Gantenbein A, Marziniak M, et al. Triptans in orgasmic headache. Cephalalgia 2006;26:1458-1461.

9. PREEMPTIVE TREATMENT
 Indomethacin 25-50 mg taken 30-60 minutes before sexual activity
 Sumatriptan 50-100 mg taken 30-60 minutes before sexual activity
Nascimento, B., & Mulhall, J. P. (2018). Sexual Headache.

10. PROPHYLACTIC TREATMENT
 Propranolol 120-240 mg/day or metoprolol 100-200 mg/day (duration: 2-6 months)

11. SUMMARY
 Exclusion of potential life-threatening differential diagnoses
 Benign nature
 Good prognosis
 Indomethacin or triptans
 Prophylactic: beta blockers

12. THANK YOU