In the heat of the moment: prevalence and clinical characteristics of headache associated with sexual activity (head HEATS study)

Abstract Background Headache associated with sexual activity (HAS) is an uncommon and understudied primary headache disorder. Previous epidemiological studies have estimated a lifetime prevalence of approximately 1.0–1.6%, although the true prevalence remains uncertain because symptoms related to sexual activity may be underreported. Objective This study aimed to assess the prevalence and clinical characteristics of HAS and its co-occurrence with other primary headache disorders in a university-based cohort. Methods A cross-sectional questionnaire study was conducted among students and employees at Martin- Luther-University Halle-Wittenberg, Germany. Of 1213 distributed questionnaires, 606 with complete age and sex information were included in the final analysis. Continuous variables were assessed for normality and compared using non-parametric methods when appropriate. Categorical variables were compared using two-sided Fisher’s exact tests. Associations with HAS were explored using parsimonious Firth penalized logistic regression models. Results Twenty-three of 606 participants reported HAS, corresponding to a lifetime prevalence of 3.8% (95% CI, 2.6–5.6%). Participants with HAS were older than those without HAS (median [IQR], 25 [21–34.5] vs. 21 [19–26] years; p = 0.005). Although 82.6% of participants with HAS were female, the proportion did not differ significantly between groups (82.6% vs. 68.6%; p = 0.175). Among participants with available timing data, headache occurred during sexual arousal or the buildup to orgasm in 57.9% and at orgasm in 42.1%. Clinical characteristics were heterogeneous with respect to pain quality and localization, and symptoms compatible with migraine aura were reported by 34.7%. Migraine and tension-type headache were not significantly associated with HAS. In age- and sex-adjusted Firth penalized logistic regression, primary exercise headache was associated with higher odds of HAS (aOR 4.06, 95% CI 1.41–11.72; p = 0.010). Conclusions In this university-based questionnaire study, 3.8% of participants reported symptoms compatible with HAS. The clinical presentation was heterogeneous, and primary exercise headache was associated with higher odds of HAS after adjustment for age and sex. Given the small number of HAS cases, questionnaire-based case ascertainment, and potential selection and response bias, these findings should be considered exploratory and should not be interpreted as population-representative prevalence estimates. Larger studies using clinician-confirmed diagnoses are needed to validate these findings.