Authors
Anjali Chacko, Simrah Siddiqui, MS, Lily Nguyen, MD, John Janousek, DO, and Kelly Thomson, MD
Introduction
Idiopathic Intracranial Hypertension (IIH), formerly known as benign intracranial hypertension, is a syndrome defined by a rise in intracranial pressure without apparent cause that can present with headaches, papilledema, or diplopia. Presentation is variable, with only 5% of patients demonstrating papilledema (1), and some patients presenting without headache (2). Orgasm associated headache is a rare symptom of IIH and, to the authors' knowledge, has only been documented in adolescent males (3). We discuss a novel case of a 44 year-old female with IIH who presented with pre-orgasmic headache.
Case Presentation
A 44 year-old female with hypercholesterolemia and a remote history of migraines 15 years ago presented to the ED with the “worst headache of [her] life”. The headache had begun 48 hours prior to presentation and was a crushing pain that began at the top of the patient's head and radiated to her neck. The headache had begun right before orgasm, and the patient endorsed dizziness but denied weakness, neck stiffness, photosensitivity, tinnitus, nausea, or vomiting. The patient reported 2 similar episodes in the 1.5 weeks prior to admission, each beginning prior to orgasm and resolving within an hour. Vital signs were unremarkable, and the patient had no neurological deficits on exam. CTA showed moderate narrowing in the left MCA M1 segment and minimal narrowing of the mid basilar artery. MRI showed a prominent sella with a small pituitary, suggestive of IIH. There was no papilledema on exam, but lumbar puncture demonstrated elevated opening pressure of 36 cm H20. MRV of head showed high-grade stenoses of bilateral distal transverse sinuses without signs of venous sinus clot, which supported the diagnosis of IIH. Patient was discharged on acetazolamide.
Discussion
This is a novel case of an adult female with IIH presenting solely with pre-orgasmic headache. Primary headaches associated with sexual activity have been well-documented in the literature, but it is a diagnosis of exclusion, made only after diagnoses such as aneurysms and intracranial hypertension have been excluded (4). Given this patient's description of the headache as “the worst headache of [her] life”, it was also important to rule out subarachnoid hemorrhage (SAH), which has a strong association with headaches provoked by intercourse (5, 6). The patient's head CT and LP were negative for SAH. While this patient did not present classically, the MRI findings of reduced pituitary gland height and transverse venous sinus stenosis suggest IIH (7). This case illustrates the need for thorough neurological workup in patients presenting with intercourse related headaches.
References
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2. Eren Y, Kabataş N, Güngör Yavaşoğlu N, et al. Idiopathic intracranial hypertension without headache: a case report and literature review. Agri. 2018;30:142-145. [PMID: 30028481] doi:10.5505/agri.2017.70370
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4. Utku U. Primary headache associated with sexual activity: case report. Med Princ Pract. 2013;22:588-589. [PMID: 23652575] doi:10.1159/000350415
5. Pascual J, Iglesias F, Oterino A, et al. Cough, exertional, and sexual headaches: an analysis of 72 benign and symptomatic cases. Neurology. 1996;46:1520-1524. [PMID: 8649540] doi: 10.1212/wnl.46.6.1520
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7. Mallery RM, Rehmani OF, Woo JH, et al. Utility of magnetic resonance imaging features for improving the diagnosis of idiopathic intracranial hypertension without papilledema. J Neuroophthalmol. 2019;39:299-307. [PMID: 30829949] doi:10.1097/WNO.0000000000000767
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