Primary cough headache, primary exertional headache, and primary headache associated with sexual activity

Activity-related headaches can be brought on by Valsalva maneuvers ("cough headache"), prolonged exercise ("exertional headache"), and sexual excitation ("orgasmic headache"). These headaches account for 1-2% of the consultations due to headache in a general neurological department. These entities are a challenging diagnostic problem as they can be primary or secondary and as their etiologies differ depending on the headache type. About 50% of patients with cough headache will show no demonstrable etiology, while the other half will be secondary to structural lesions, mostly a Chiari type I malformation at the foramen magnum level. As compared to the primary variety, secondary cough headache begins earlier (average 40 versus 60 years), is located posteriorly, lasts longer (years versus months), is associated with posterior fossa symptoms/signs, and does not respond to indomethacin. Patients with secondary cough headache show difficulties in cerebrospinal fluid circulation in the foramen magnum region in dynamic magnetic resonance imaging studies and preoperative plateau waves, which disappear after posterior fossa reconstruction. Headaches provoked by physical exercise and sexual headache have many points in common. In contrast to cough headache, secondary cases are rare, and sentinel subarachnoid bleeding is the most frequent etiology. The mean age at onset for primary headaches provoked by physical exercise and sexual activity is similar (40 years); they share clinical characteristics (bilateral, pulsating) and respond to beta-blockers. In conclusion, provoked headaches account for a low proportion of headache consultations. Cough headache is a different condition when compared to headache due to physical exercise and sexual activity, which are clinical variants of the same entity.