Letter to the Editor

Orgasm-a new trigger factor of cluster headache?

The aetiopathogenesis of cluster headache still remains unknown. No information about the agents triggeringthe bout of cluster headache have been published. Factors known to provoke cluster headache attackscause the headache during the cluster period only (1). There are some reports on rare trigger factors as wellas reports on cluster-like attacks in the course of other diseases (2, 3, 4).

The recent classification of the International Headache Society distinguishes between three types ofheadache associated with sexual activity, one of them being "a sudden severe ('explosive') headacheoccurring at orgasm" (5). Due to its character this form of headache should be differentiated, among others,from pain caused by sub-arachnoid haemorrhage and arteriovenous malformation (6, 7). This paperconcerns a case of cluster headache provoked by orgasm. No similar report can be found in the availableliterature.

Case report

A 31-year-old man of Muslim religion, Persian by origin, who had been living permanently for several years inLund (Sweden) came to Poland for a short holiday. He was referred to me as an out-patient on 20 June 1989because of severe, left-sided, unilateral headache attacks accompanied by left eye lacrimation and left-sidednasal congestion. The pain was tearing in character and located in the left temporal and orbital area. Theheadache occurred at least once a day and lasted for about 15-30 min. This was the first time the patient hadexperienced this type of headache and he never before suffered from any other type of headache. It was myimpression that the main reason he sought medical advice was the fact that the headache attacks occurredexclusively at orgasm. During his short stay in Poland the patient was very sexually active with numerousfemale partners. On the second day of his stay in Poland he experienced, for the first time, the attackassociated with orgasm. This occurred again for the next three days. Intercourse without orgasm did notcause pain, however. The patient, being a Muslim, did not drink any alcohol. I was the first physician thepatient had consulted. General and neurological examination did not reveal any abnormalities. The patientcould not be hospitalized or CT scanned as he intended going back to Sweden two days later.

Discussion

The patient's pain attacks showed all the characteristic features of cluster headache. Their repetition on thesubsequent days, good general status of the patient and the lack of any meningeal signs excludedsub-arachnoid haemorrhage as the cause of the pain. No further diagnostic steps could be taken due to thepatient's refusal and his intention to return to Sweden.

This report is based on the one and only visit of the patient. However, the rare and unusual character ofthe headache attacks seems to be sufficient justification for the publication. I consider the diagnosis of clusterheadache related to orgasm as the most appropriate one in the discussed case. The point of discussion iswhether or not to consider these attacks as cluster or cluster-like headaches, and the question must be leftopen at the moment. It may be presumed that orgasm was the trigger factor. However, the known provokingfactors for attacks act only in the bout of cluster headache, so the patient had to be in the bout. It is knownthat the first bout of episodic cluster headache is often atypical with usually shorter and less severe painattacks. I did not find any reports of similar cases in the literature. The presented case is different from thosereported

by Maliszewski et al. (8) with headache attacks not so obviously connected with orgasm. This case reportgives more information about triggering factor but of course does not explain the mechanism of provocationor the cluster headache itself.

References

1. Ekbom K. Pathogenesis of cluster headache. In: Blau JN ed Migraine. London: Chapman & Hall 1987:223-37

2. Messert M, Black JA. Cluster headache, hemicrania and other head pains: morbidity of carotidend-arterectomy. Stroke 1987;9:559-63

3. Ramoli M, Cudia G. Cluster headache due to impact superior tooth: case report. Headache1988;28:135-6

4. Takeshima T, Nishikawa S, Takahashi K. Cluster headache like symptoms due to sinusitis: evidencefor neuronal pathogenesis of cluster headache syndrome. Headache 1988;28:207-8

5. Headache classification committee of the international headache society. Classification and diagnosticcriteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988;suppl 7:1-96

6. Lundberg PO, Osterman PO. The benign and malignant forms of orgasmic cephalalgia. Headache1974; 13:164-5

7. Lance JW. Headaches related to sexual activity. J Neurol Neurosurg Psychiatry 1976;39:1226-30

8. Maliszewski M, Diamond S, Freitag FG. Sexual headaches occurring in cluster headache patients. ClinJ Pain 1989;5:45-7

Andrzej Klimek, M.D., Plac Dabrowskiego 1, 90-249 Lódz, Poland; Accepted 15 June 1990