Pornography headache (2017)

Headache associated with sexual activity (HSA) is a constellation of sex-related headache disorders. Intercourse is the leading sexual act, following by masturbation [1]. Till now, there is only one person who is reported to suffer headache elicited by pornography [2]. Herein, we report another patient in whom two novel findings support pornography headache a sexuality-specific pain complicated with cerebrovascular dysregulation.

A 40-year-old man described holocranial throbbing and dull headache, especially at vertex, neck and bilateral temples, for 1 year. Pain started within 10 min after internet pornography watching and its intensity progressively increased without orgasm. The pain subsided only until when patient stopped watching. Patient denied any aura, associated symptom, autonomic feature or blood pressure elevation during pain. However, subjective or objective sexual arousal (SA), such as facial hotness, palpitation, rapid breathing, dry throat and/or penile hardening, preceded the onset of pain. The index pain was only provoked by pornography, but not videos or pictures containing non-erotic or neutral materials, recalling the sexual scenario in pornography, solo/partnered masturbation alone without pornography, nude body of partner in intercourse, hearing intercourse sound or verbal sexual invite, or non-sexual exertional activity. In regard to the content of erotic video, heterosexual orgy was the strongest stimulus in especially with explicit close-up. The intensity was moderate for one-to-one heterosexual intercourse, lesbian act and anal intercourse. Male homosexual act did not provoke any pain. The pain was stronger to younger actresses than older ones without difference for ethnicity or under imaginary of participation.

The lifetime prevalence of HSA is estimated to be 1%. Recently, Anand & Dhikav [2] reported the first formal patient of pornographic headache. They speculated the pain being due to trigeminovascular effect and muscle contraction, basing on a high prevalence of migraine in HSA and a preorgasmic attack in their patient. However, their patient and ours do not experience migraine or trigeminovascular headache and preorgasmic pain is not unique to muscle contraction. In our patient, there are two novel findings relating to this peculiar headache, namely, SA activation before and vasoconstriction during pain. These findings suggest pornography headache a sexuality-specific pain involving with SA network, such as hypothalamus which regulates autonomic reaction.

In index patient, the pain principally occurs with and its intensity is parallel to the magnitude of SA, implicating arousal activation likely the gatekeeper and modulator for pornography headache. Generally, the magnitude of activation depends on a couple of factors, such as gender, age, level of sex hormones, sexual attitude, and mode of sexual stimuli. A specific higher activation to heterosexual acts, imagination of self-casting and female actress in index patient support that sexual orientation and preference [3] and imaginary of participation [3] also activates or reinforces his SA. Interestingly, pain is only specific to SA elicited by pornography but not in other real-life sexual activity in index patient. This condition suggests a different erotic signal pathway and pain mechanism existing between the pornography headache and other HSA despite of similar visually erotic stimulation.

An asymmetrically higher angle-corrected cerebral blood velocity during pain presumes SA-mediated cerebrovascular dysregulation to be a possible source of pain in index patient. The pattern of increment unlikely relates to visually erotic or violent stimulation, visually non-erotic stimulation in migraineurs or painful feeling. Rather, it is compatible with focal vasoconstriction, such as the reversible cerebral vasoconstriction syndrome. In fact, dysregulatory vasoconstriction occasionally contributes to preorgasmic headache in HSA patients [4] similar to ours. Taken together, pornography headache is proposed a SA-mediated cerebrovascular dysregulation resulted from visuoneural uncoupling to erotic stimulus. However, it may also be affected by other factors, such as stress from anxiety, shame, guilty or other negative emotions, especially in religious community.

Our patient responded favorably to preventive indomethacin as seen in other indomethacin responsive headache syndromes [5]. Indomethacin occasionally benefits for preorgasmic and orgasmic type of HSA similar to ours. Its pharmacological mechanism is postulated to suppress inflammation by competitive inhibition on the cyclo-oxygenase 1 and 2, phospholipase A2, or gluthation S-transferase. In the previous pornography headache patient, pain was relieved by the ibuprofen and paracetamol combo [2]. Therefore, short-termed prophylaxis of indomethacin or ibuprofen is suggested for pornography headache.

Pornography headache is a distinguished headache disorder pertaining to pornography use and is different from other HSA. It is proposed to result from visuoneural uncoupling with SA-mediated cerebrovascular dysregulation. Preventive treatment with indomethacin is beneficiary. Pornography headache should be cautioned as vasomotor change is present. It may be underestimated in general population as pain-killer overuse may mask the actual incidence in real world.

Authors, hereby, state to have no conflict of interest in this report.