Post Hemorrhagic Hemicrania Continua In A Patient With ...

Article ID: WMC00881 2046-1690

Post Hemorrhagic Hemicrania Continua In A Patient
With Orgasmic Paroxysmal Hemicrania

Corresponding Author:
Dr. Daniel Jacome,
Adjunct Associate Professor, Dartmouth Hitchcock Medical Center. Department of Neurology , One Burnham
Street, Suite 2, Turners Falls, MA , 01376 - United States of America

Submitting Author:
Dr. Daniel E Jacome,
MD, Dartmouth Hitchcock Medical Center Department of Neurology, One Burnham Street, Suite 2, 01376 -
United States of America

Article ID: WMC00881
Article Type: Case Report
Submitted on:07-Oct-2010, 03:38:02 AM GMT Published on: 07-Oct-2010, 07:57:56 PM GMT
Article URL: http://www.webmedcentral.com/article_view/881
Subject Categories:NEUROLOGY
Keywords:Paroxysma Hemicrania, Hemicrania Continua, Sexual Headache, Sentinel Headache, Hemorraghic
Stroke, Intracranial Aneurysm

How to cite the article:Jacome D . Post Hemorrhagic Hemicrania Continua In A Patient With Orgasmic
Paroxysmal Hemicrania . WebmedCentral NEUROLOGY 2010;1(10):WMC00881

Source(s) of Funding:
No funding

Competing Interests:
No Conflict of Interest

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Post Hemorrhagic Hemicrania Continua In A Patient
With Orgasmic Paroxysmal Hemicrania

Author(s): Jacome D

Abstract lacrimation and conjunctival irritation are common but
around one third of the patients report no associated
BACKGROUND: In its classic form sentinel headache cranial dysautonomic symptoms. Although PH is a
heralds an underlying intracranial aneurysm near primary headache disorder, exceptionally hemorrhagic
rupture. Headache related to sexual activity is stroke may present as PH. Bazan, et al, recently
normally benign and does not represent a sentinel described a patient with PH secondary to a contra
headache to ulterior intracranial bleeding. Hemicrania lateral upper brain stem hemorrhage [3]. In chronic PH
continua is a primary headache only exceptionally the pain is consistently recurrent with a variable
precipitated by acute central nervous system (CNS) frequency, ranging from one to ten attacks a day, to
pathology. one attack every few days in very rare cases {1, 2].
METHODS: Clinical case history, repeated Hemicrania continua is not as infrequent as first
neurological examinations, ancillary imaging believed. In the overwhelming number of cases it
procedures and review of literature. constitutes a primary headache. Exceptional post
RESULTS: A patient with recurrent orgasmic traumatic cases, and secondary cases due to brain
headache manifested as severe left hemicrania of tumor and to HIV infection, have been described [4]. A
abrupt onset lasting for several hours, developed in patient with HC associated with an ipsilateral
the course of her illness a very severe left side unruptured internal carotid aneurysm was reported by
headache while performing physiological valsalva Vikelis, et al [5]. Hemicrania continua may evolve from
during defecation, associated with an opposite side episodic PH and falls within the category of chronic
right anterior capsule intracranial bleed. Subsequently daily headache, along with chronic tension type
she transitioned into hemicrania continua without headache, newly daily persistent headache and
dysautonomia, ameliorated by valproic acid and by chronic migraine. Hemicrania continua is
diet-induced weight loss. Her imaging studies showed characterized by unilateral continuous headache,
no evidence of arteriovenous malformation or waxing and waning in intensity. The baseline
intracranial aneurysms. headache may be accompanied of autonomic signs,
CONCLUSION: On this unusual patient, orgasmic stabbing head pain or jabs and jolts, nausea and
hemicrania was premonitory of a contralateral sound and light intolerance. In the review of HC
hemorrhagic stroke, representing a variant of sentinel provided by Peres, et al, on their own cases and those
headache later evolving into hemicrania continua. collected from the literature, concurrent autonomic
symptoms occurred in between 63% to 73% of the
Introduction patients [4]. Around 25% of those patients with
autonomic symptoms reported only a single autonomic
Paroxysmal hemicrania (PH) is a variant of trigeminal symptom.
autonomic cephalagia (TAC) a family of headache Normally PH and HC are not triggered by sexual
disorders also encompassing cluster headache and activity, and orgasmic headache does not transition
short lasting unilateral neuralgiform headache with into HC, although one unusual patient previously
conjunctival injection and tearing, or SUNCT reported in the literature, developed headaches
syndrome [1, 2]. Three types of PH are identified: triggered by emotion, following three episodes of coital
episodic, chronic and hemicrania continua (HC). In cephalalgia [6]. A patient with HC evolving from
episodic PH the patient reports unilateral, paroxysmal, ipsilateral cluster headache responded to the
severe, sharp, throbbing or stabbing pain, with no administration of valproic acid [7].
universal precipitants and no aura [1]. Most attacks
have no circadian periodicity. The duration of the Case Report
attacks fluctuates between minutes to hours with a
mean duration of fifty eight minutes [1, 2]. Autonomic A 48 year old female was referred for neurological
features in the form of ipsilateral rhinorrhea, consultation because intense left side continuous
throbbing headache with superimposed stabbing pain,

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interfering with her sleep and not responding to Orgasmic, coital or sexual headache (SH) refers to a
common analgesics. Her headache followed a small type of exertional headache precipitated by coital or
right capsular hemorrhage, triggered by straining hard masturbatory sexual activity [8, 9]. Pre-orgasmic- and
during defecation because of constipation. The initial orgasmic headache are recognized by the
head pain concurrent with the bleeding was extreme International Classification of Headache disorders, but
(10/10 in VAS). She gave history of preceding according to Nick and Bakouche, there is an additional
transient episodes of similar left side headaches form of post coital headache lasting from hours to
qualified as 8/10 in the VAS, coinciding with orgasms days, as a sequel of orgasmic headache [9]. The
during sexual intercourse for the last several weeks. orgasmic “explosive” type of headache is acute in
Orgasmic headaches lasted for a few hours. During an onset and very intense, to the extreme that the patient
early emergency department visit while experiencing feels compelled to seek emergency care, fearing a
the original sexual headache, she was found bleeding into the brain. Most SH are benign;
hypertensive. Her neurological examination and her exceptionally subarachnoid hemorrhage or embolic
head computerized tomography (CT) were found strokes are complications of SH. Of specific relevance
normal at the time (illustration 1). Her subsequent to this case, Finelli reported a patient with an
head CT following her extreme hemicrania with intracranial basal ganglia hemorrhage triggered by
defecation revealed a right anterior capsular bleed on sexual intercourse, secondary to the rupture of a
the opposite side to the headache (illustration 2). vascular malformation [10]. Finnelli’s clinical example
There was no mass effect, subarachnoid hemorrhage underscores the indication for performing imaging
or hydrocephalus. Her head computerized tomography procedures including CT angiogram (CTA), in patients
angiography (CTA) showed no aneurysms, beaded or with SH, especially since other intracranial vascular
stenotic vessels and no arteriovenous anomalies. pathologies may coexist, such as basilar artery
There were no signs of proliferating angiopathy dissection and basilar artery stenosis [11]. Although
(“Moyamoya disease”). When symptomatic, and later post stroke pain may complicate up to two thirds of
on when asymptomatic, there was no signs of ocular patients suffering strokes, usually the pain takes the
ptosis, miosis, weakness of eye movements, ipsilateral form of lateralized complex regional pain syndrome to
rhinorrhea, ocular injection or facial flushing on the involved (paretic) side, instead than presenting as
repeated neurological examinations. The remaining of PH or HC, as in the current patient. Valsalva
her repeated general physical and neurological maneuver precipitates intracranial bleed and cluster
examinations was normal including her blood pressure headache in exceptional individuals [12, 13]. Valsalva
readings. Her past medical history was significant for is one of the precipitating mechanisms adduced in the
hypertension, insulin dependent diabetes mellitus, genesis of exertional, cough, laughing and crying
hyperlipidemia and nephrolithiasis. She had no history headache in general, and of SH in particular. Valsalva
of migraine. Medications included simvastatin, mediated headache seemingly results from transient
lisinopril, metformin, fluoxetine and insulin at variable intracranial hypertension and pulsing maximal
doses. She had no allergies. She had family history of distention of the intracranial vessels, on those
multiple sclerosis but no family history of intracranial individuals with a migraine diathesis, perhaps
aneurysms, hemorrhagic stroke or migraine. facilitated by incremental central pain sensitization.
Significant clinical information obtained on her review Central sensitization can explain why the persistent
of symptoms was limited to occasional tingling of the headache in some patients with exertional migraine,
toes, interpreted as early signs of diabetic i.e, brought by weight lifting, on whom valsalva is only
polyneuropathy. She was prescribed valproic acid at a the initial trigger. As in the specific examples of SH
dose of 500 milligrams a day along with tramadol 50 discussed above, imaging of the brain is justified on
milligrams four times a day, as needed. Although she patients with exertional headache, because the
was not morbidly obese she also embarked on a occasional occurence of secondary valsalva-induced
formal weight loss program. In six weeks her headache, on individuals with occult Arnold Chiari
continuous headache subsided. In follow up visit malformation and cerebellar tonsillar ectopia,
fifteen months later she reports milder episodes of originating from abnormal cerebrospinal fluid
orgasmic headache; blood pressure readings and hydrodynamics [14].
neurological examination continue normal. Additional pathophysiological explanations advanced
for the specific appearance of SH are systemic
Discussion hypertension during sexual activity, loss of normal
cerebral vascular autoregulation, and painless,
segmental or diffuse, persistent cerebral arterial

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vasospasm [15]. When vasospasm is present in a References
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WMC00881

Illustrations
Illustration 1

PRE-HEMORRHAGIC POST-ORGASMIC NORMAL HEAD CT

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WMC00881

Illustration 2

HEAD CT SHOWS ACUTE RIGHT ANTERIOR INTERNAL CAPSU

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ULE HEMORRHAGE

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