“Not tonight dear, I’ve got a headache” isn’t always an excuse. Sometimes it’s a real condition

Headaches provoked by sex affect about 1 per cent of people at some time. But, fortunately, the problem disappears as mysteriously as it arrives.

By Phil Whitaker

Kay had been on the verge of orgasm when she was struck by a sudden headache. It was so severe she’d had no choice but to call an instant halt, the pain obliterating all passion. She felt it over the back of her head and in her neck, too. She’d never had anything like it before.

“It went off fairly quickly though,” she told me on the phone. “Maybe a quarter of an hour. So we tried again mid-afternoon. The same thing happened. And we tried again in the evening – same again, but that one lasted longer. I’ve actually still got a faint headache now.”

I brought her into surgery. Headaches like this are called “thunderclap”, a term that evokes both the suddenness of their onset and their ferocity. Kay’s blood pressure was normal; her neck moved freely in all directions; there was no sign of any weakness or incoordination.

“If you’d phoned me yesterday, after the first episode,” I told her, “you’d have ended up in a CT scanner. But, as it is, I think you’ve made the diagnosis by yourself.”

The concern with a first thunderclap headache is that it might represent a bleed from a brain artery – a subarachnoid haemorrhage (SAH). A full-blown SAH can be catastrophic, leading to severe disability or death. A substantial proportion of SAHs are preceded by a “sentinel” or warning bleed, though – enough to cause a sudden severe headache, but without resulting in neurological damage. If one correctly diagnoses a sentinel bleed, there’s a chance for a neurosurgeon or interventional radiologist to seal the weak spot in the arterial wall and prevent subsequent complete rupture. SAHs can sometimes be provoked by sexual exertion, so had Kay presented the day before, I wouldn’t have hesitated to send her into hospital for an emergency scan.

But Kay and Mike, in their persistence in trying to finish what they’d started, had clinched the alternative diagnosis: coital cephalgia. I outlined the basics of this strange condition for her. It probably affects about 1 per cent of people at some time. The mechanisms are unknown, but the defining characteristic is headache provoked by sex. There can be some diagnostic challenges: an affected individual might not experience it in every instance of intercourse, and some people find that non-sexual exertion will also bring the headache on. But for Kay it was clear-cut: three thunderclaps on the same day, each when approaching orgasm, and each subsequently settling without after-effect – this could really only be one thing.

Fortunately, coital cephalgia disappears as mysteriously as it arrives. Some patients have a single episode; those with recurrent attacks will usually find them settling spontaneously over a few weeks or months.

The case left me feeling strangely cheered. Kay and Mike have been at home together for much of the past year on combinations of furlough and remote working. They have three sons between the ages of seven and 12 who are a handful at the best of times, and are decidedly boisterous and restive under home-school confinement.

I have no idea how long it had been since Kay and Mike had enjoyed any time together that wasn’t marred by end-of-the-day exhaustion. Nor do I know how they had managed to farm the boys out – given that it probably meant bending some lockdown rule or other. But they had relished this stolen time – jumping delightedly into bed after lunch, only to be thwarted by coital cephalgia. And then were so determined to make the most of the opportunity that they tried not once but twice more, only for each attempt to meet with the same fate.

It seemed to say something about this life we are living, and the all too human desire to make the best of it – with, in this case, tragicomic results.