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HRT-induced primary headache associated with sexual activity: A case report
Salwa Kamourieh1, Susie Lagrata1
1Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology, London, UK.
Post Reproductive Health
|November 13, 2025
Summary
Primary headache associated with sexual activity (PHASA) can be triggered by hormone therapy. A case study shows that increasing transdermal estradiol dose led to orgasm-induced headaches, which resolved upon dose reduction.
Area of Science:
- Neurology
- Endocrinology
Background:
- Primary headache associated with sexual activity (PHASA) is rare and can mimic serious neurological conditions.
- Hormone replacement therapy (HRT) is a potential factor in PHASA.
Purpose of the Study:
- To report a case of PHASA potentially linked to transdermal estradiol therapy.
- To highlight the importance of considering HRT as a trigger for PHASA.
Main Methods:
- A case report of a 47-year-old woman with a history of migraine with aura.
- Observation of headache and libido changes following an increase in transdermal estradiol dose.
- Resolution of symptoms after reducing the estradiol dose.
Main Results:
- Thunderclap headaches exclusively at orgasm occurred after increasing transdermal estradiol from 50 µg to 75 µg twice weekly.
- Neuroimaging results were normal.
- Headaches and increased libido resolved upon reducing the estradiol dose to 50 µg.
Conclusions:
- Transdermal estradiol therapy, specifically dose increases, may be a reversible trigger for PHASA.
- Clinicians should consider HRT as a potential cause in patients presenting with PHASA.
- Further investigation into the relationship between HRT and sexual headaches is warranted.
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