Station 57
Micheal Stevenson
Age: 32 years old male
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Ask about the onset of the headache
- Ask about the location of the headache (e.g. frontal, parietal, generalised)
- Ask about the nature of the headache (e.g. pounding, thunderclap, dull ache)
- Ask whether the headache radiates anywhere
- Ask about the severity, relieving or aggravating factors, and known triggers
- Specifically explore red flag triggers such as headaches brought on by coughing, sneezing, or physical exertion, neck stiffness, visual changes, neurological symptoms (e.g. weakness), and sensitivity to light or sound
- Ask about associated symptoms including nausea, vomiting, and autonomic features such as eye redness or watering, nasal congestion or runny nose, and facial flushing, which may suggest a cluster headache.
- Ask if he has experienced this type of headache before and whether it feels similar to his usual migraines.
- Ask how the headache is affecting his day-to-day life, particularly his sexual activity
- Ask about social history including smoking, alcohol intake, and occupation
- Explore the patient’s ideas, concerns, and expectations (ICE)
- Make a diagnosis of sexual headache
Example of explanation to patient
Micheal, the type of headache you’ve described is known as a ‘sexual headache’. These can happen during or just before orgasm and are often harmless, related to changes in blood pressure or muscle tension during sexual activity. However, because this is your first time experiencing this kind of headache and it came on quite suddenly, we do need to rule out anything more serious, just to be safe.
One rare but important condition we need to exclude is something called a subarachnoid haemorrhage. That’s when bleeding occurs around the brain, and while it’s uncommon, it can sometimes present in this way. I want to stress that this is mainly a precaution, as most headaches like yours are not caused by anything dangerous. But given the sudden onset and the context, it’s safest for us to check things properly.
For this reason, I’ll be referring you to the acute medical unit at the hospital today. They’ll carry out the necessary tests, which may include scans of your head and, if needed, a lumbar puncture; that’s a procedure where a small sample of fluid is taken from your spine, to make sure everything is okay.
If everything comes back clear, which is often the case, then we can talk about starting medication to help prevent these headaches. One option is propranolol, which may reduce how often they occur. There’s also a tablet called indometacin, which can be taken about an hour before planned sexual activity to help stop the headache from happening in the first place.
Management
Management
- Offer referral to the acute medical unit or emergency department for urgent CT head to rule out subarachnoid haemorrhage, as this is a first presentation of sexual headache
- Advise the patient that this is a precautionary step to ensure there is no serious underlying cause
- Explain that once serious causes are ruled out, preventive treatment can be considered
- Consider starting prophylactic medication such as propranolol (40–240 mg daily).
- Indometacin, taken at a dose of 25–75 mg either regularly or approximately 60 minutes before planned sexual activity, may help prevent the onset of headache
- Triptans may offer benefit for individuals who cannot tolerate indometacin, particularly when taken 60 minutes prior to sexual activity.
- Advise on general lifestyle measures including weight loss if overweight, regular physical activity, and taking a more passive role during intercourse, which may help reduce symptom frequency
- Offer follow-up after discharge from the acute medical unit or emergency department to review the outcome of hospital assessment and initiate prophylactic treatment as appropriate
- Provide safety net advice: if symptoms worsen on the way to hospital or new symptoms develop, advise the patient to stop and call emergency services; recommend that he avoid driving himself and arrange for someone else to take him to hospital
Learning point from this station:
Primary sexual headache is triggered by sexual activity, typically starting as a dull, bilateral ache that intensifies with sexual arousal and becomes suddenly severe at the point of orgasm. It occurs in the absence of any underlying intracranial pathology and is approximately three times more common in males.
Risk Factors include
- Personal history of migraine or exertional headache
- Obesity
- Stress
- Intensity of sexual excitement
- Family history of headache or occlusive arterial disease
Even in the absence of red flag features, clinicians should maintain a low threshold for investigating subarachnoid haemorrhage, particularly in first-time presentations. Prompt exclusion of serious intracranial pathology is essential to ensure safe and accurate diagnosis and appropriate management.