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Exertion, Sex, Sleep, Cough Triggered Primary Headaches
Exertional Headache – Primary Orgasmic/Preorgasmic Headaches – Cough and Hypnic Headaches – Typical Triggers – Treatment
Please note that this headache type is not triggered by straining but rather by any type of strenuous workout. Strain related headache is a different phenomenon described below (primary cough headache). It has a different pattern and affects rather older age groups.
Primary exertional headache often has an explosive pattern at onset, typically in the back of the head or in the whole head. It soon becomes throbbing, especially in response to the change of body position.
There are must be no associated symptoms. Presence of nausea, vomiting, hypersensitivity to light, or poor sense of well-being rather point to alternative diagnosis. Considering sudden onset of exertional headache in many cases, subarachnoid hemorrhage is always a prime concern. For this reason, the very first attack requires evaluation for the presence of a cerebral aneurysm. Other diagnostic considerations in suspicious cases are carotid/vertebral artery dissection or pituitary apoplexy.
Exertional headache may be as short as 5 minutes or it may stay for up to 2 days.
Indomethacin may be effective if taken prior to the exercise. Short break in the exercise program prevents the headache recurrence in some patients. Alternative work out type may also be beneficial.
Primary exertional headache is not a contraindication for a strenuous physical activity per se, as long as potential serious conditions are ruled out. After initial presentation, subsequent course of this headache type in unpredictable. Long term suffering from primary exertional headache is rather an exception.
There are no associated symptoms.
It rarely starts before age 40. Once started, cough headache may continue unremitting for years or may come and go. Individual headache pattern is unpredictable.
Primary cough headache has a decent response to preventive treatment with Indomethacin.
Cough headache requires diagnostic work up, considering similar headaches may be produced by Chiari malformation or by brain tumors.
Primary Sex Associated Headache
Preorgasmic headache is dull, gradually increasing in intensity headache in the back of the head and the upper neck. Headache is building up together with the level of excitement.
Patients are usually aware of the sensation of tension in the jaw and the neck. Voluntary attempt to relax the muscles may help.
Preorgasmic headache is less common than orgasmic headache.
Primary orgasmic headache is a sudden explosive headache, which quickly turns into a throbbing holocranial (whole head) pain. As the name implies, it starts during or around the time of orgasm. The headache may be relatively short or it may last for hours.
Orgasmic headache appears to be caused by brain blood vessel spasm, similar to primary thunderclap headache.
Subarachnoid hemorrhage due to aneurysm rupture is associated with sexual intercourse in 10% of cases. This is why orgasmic headache has to be regarded as an intracranial hemorrhage, unless proven otherwise on diagnostic testing. Head CT, Spinal tap, Brain MRI and MRA are mandatory for the evaluation.
Recommended treatment is a prophylactic use of Indomethacin or Triptans 30 to 60 minutes prior to the intercourse. Another option is a daily prophylactic treatment with Propranolol; especially in a setting of some other conditions requiring this type of medication, such as migraine or hypertension.
Triptans are effective for abortive treatment of orgasmic headache in about 50% of cases. Sumatriptan nasal spray can be a reasonable option.
Diagnostic criteria for hypnic headache require more than 15 “headache-nights” per month on average.
Associated symptoms (nausea, sensitivity to light and noise) are possible but they do not have to be present. Headache onset is almost exclusively after age 50.
Pattern similar to cluster headache makes the cause of this syndrome likely to be connected to hypothalamus.
Hypnic headaches are benign but they might be simulated by multiple conditions; thus, it requires an extensive neurological work up. The main concern is a secondary headache due to temporal arteritis, brain tumors or metastasis, hydrocephalus or subdural hemtoma; all are capable of causing nocturnal headaches. Sleep apnea is another classical cause of a sleep associated chronic headache.
Hypnic, or “alarm clock”, headache responds well to caffeine or to a cup of coffee before bed. Lithium and Indocin are very effective as well. The list of potentially helpful medications is long. Melatonin at a bed time is a logical potential alternative.
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