Answer: Benign Sexual Headache

Discussion: For patients with a history of DCIS, a common consideration is the use of endocrine therapy for secondary prevention.

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The most commonly administered agent is tamoxifen,1 though accumulating data suggest that for postmenopausal women, aromatase inhibitors may also be effective.2

However, endocrine therapies are also associated with sexual dysfunction in breast cancer survivors, with the most common symptoms being related to vulvovaginal side effects,  which commonly includes pain related to penetrative intercourse (dyspareunia). 

However, Joan was not taking either of these medications to explain her symptoms. In addition, she did not appear to have any concerns of her body image, which could lead to issues with intimacy or attraction. Indeed, she appeared quite comfortable in her own skin, and presented with a desire to be with a partner.

Given that she had a prior evaluation to rule out an anatomic etiology, the long-standing nature of her symptoms, and the specific events that incited her headaches, her likely diagnosis is benign sexual headache (BSH; also referred to as coital cephalagia, primary sexual headache).

BSH is a clinically recognized headache disorder that occurs exclusively during, or immediately after sexual activity. It is a rare condition with a reported incidence of 0.25% to 1.0% in the general population.3

The diagnosis is one of exclusion and more serious etiologies must be ruled out, including subarachnoid hemorrhage, cerebral infarction, or reversible vascular phenomenon.4-6

Further classification of BSH can be made relative to the timing of symptom onset during sexual intercourse (eg, pre-orgasmic, or type 1; orgasmic, or type 2; or following orgasm, type 3).6

The etiology of BSH remains unclear, likely due to the rarity of the condition. Although the presence of another primary headache syndrome appears to be a risk factor for BSH,7 it was not present in this patient.

Following the exclusion of more ominous conditions, patients with BSH have a favorable prognosis. Treatments are available, and despite the lack of high-quality data, they appear to be effective.

For patients with frequent and regularly occurring headaches associated with sex, indomethacin (25 mg/day to 50 mg/day) or propranolol (40 mg/day to 200 mg/day) taken before intercourse may be of use, though more frequent administration may be indicated as prevention.6

*Name and case details have been changed to protect patient privacy.


  1. Eng-Wong J, Costantino JP, Swain SM. The impact of systemic therapy following ductal carcinoma in situ. J Natl Cancer Inst Monogr. 2010;2010(41):200-203.
  2. Olin JL, St Pierre M. Aromatase inhibitors in breast cancer prevention. Ann Pharmacother. 2014;48(12):1605-1610.
  3. Rasmussen BK, Olesen J. Symptomatic and nonsymptomatic headaches in a general population. Neurology. 1992;4(6):1225-1231.
  4. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629-808.
  5. Valença, M. M. et al. Cerebral vasospasm and headache during sexual intercourse and masturbatory orgasms. Headache 44, 244–248 (2004).
  6. Frese, A. et al. Headache associated with sexual activity: prognosis and treatment options. Cephalalgia Int. J. Headache 27, 1265–1270 (2007).
  7. Ostergaard, J. R. & Kraft, M. Benign coital headache. Cephalalgia Int. J. Headache 12, 353–355 (1992).