Conflict of Interest: None
Orgasmic Headache Responsive to Greater Occipital Nerve Blockade
Article first published online: 26 SEP 2008
© 2008 the Authors. Journal compilation © 2008 American Headache Society
Headache: The Journal of Head and Face Pain
Volume 49, Issue 1, pages 130–131, January 2009
How to Cite
Selekler, M., Kutlu, A. and Dundar, G. (2009), Orgasmic Headache Responsive to Greater Occipital Nerve Blockade. Headache: The Journal of Head and Face Pain, 49: 130–131. doi: 10.1111/j.1526-4610.2008.01253.x
- Issue published online: 5 JAN 2009
- Article first published online: 26 SEP 2008
- Accepted for publication July 21, 2008.
- sexual activity;
- greater occipital nerve
We present a male with headache related to sexual activity. An injection of steroid and local anesthetic combination was applied to the greater occipital nerve of the symptomatic site. The orgasmic headache stopped after the procedure.
Headache related to sexual activity (HSA) is a rare benign headache disorder which could develop in 2 forms: slowly progressive (type 1) and explosive (type 2). HSA type 2 is supposedly of vascular origin; HSA type 1 is attributed to muscle contraction.1β-blockers for prophylaxis and indomethacin for preemptive therapy are recommended.2
We report a 43-year-old male with explosive HSA who responded to single greater occipital nerve (GON) injection, which contains local anesthetic and steroid.
A 43-year-old man consulted us with severe headaches during sexual activity. Headaches first started to appear approximately 4 months prior to visiting our clinic and occurred on almost every occasion that intercourse was attempted. During orgasm, the patient experienced severe headaches of an exploding quality, concentrated at the top of the head. After a few minutes, the headache spreads through the left eye and left occiput. After 15 minutes of severe headache with a throbbing quality, its severity abates and lasts for approximately 30 minutes. Headache wanes slowly and totally disappears after 30 minutes. There were no accompanying symptoms during the headache episode such as nausea, photophobia, or phonophobia.
The patient did not attempt preemptive therapy with anti-inflammatory drugs because of gastric problems. GON injection was applied to the patient's symptomatic side with 20-mg prilocaine and 125-mg methylprednisolone. During the follow-up examination after 2 weeks, the patient reported that orgasmic headache did not occur during the first attempt at intercourse, which was on the fourth day of injection. There were no orgasmic headaches through the 10th week of follow-up.
Greater occipital nerve injection has been attempted with various primary headache syndromes. Although there are variations in the injection site,3-5 application method,6 ingredients of the injection and its dosages,3-6 it seems a promising approach of therapy.3,6
Clinical studies of GON injection in cluster headache and migraine patients yielded successful results. It has been suggested that steroids play a more important role in cluster headache treatment rather than local anesthetics in the injection fluid.6 Other studies contend, however, that steroids have no role in the treatment of chronic migraine patients.5
The mechanisms of action are not well known. As afferent inputs from the cervical muscles facilitate wind-up in C-fibers in the presence of dural inflammation,7 GON blockade could abate afferent traffic from the periphery and could relieve headache. Modulation of nociceptive signaling in the central nervous system is another theory posited.3,8 It has been shown in animal studies that blocking a tiny part of the maxillary branch of the trigeminal nerve causes latence and receptive field changes in thalamic neurons.9
The patient presented here has an HSA with explosive quality that spreads from vertex to both ipsilateral eye and occiput. The headache could not be attributed to muscle contraction from its presentation, although GON injection seems to be a more plausible mode of treatment in bulk muscle spasm.
We are not able to say if local anesthetic or steroid played a role in patient amelioration. Although we cannot exclude spontaneous cessation of orgasmic headaches, occipital nerve injection seems to be a safe, cheap, and effective way of treatment for this particular kind of headache.