Headache Medicine 2021, 12(3):154-159 p-ISSN 2178-7468, e-ISSN 2763-6178
154
ASAA
DOI: 10.48208/HeadacheMed.2021.29
Headache Medicine
© Copyright 2021
Review
“To sleep”, “to cough” and “to love’: Uncommon primary headaches
Wallyson Pablo de Oliveira Souza , Yasmine Maria Leódido Fortes , Raimundo Pereira Silva-Néto
Integrated Center of Medical Specialties (CIEM) and Federal University of Delta of Parnaíba, Parnaíba, Brazil
Abstract
Introduction
There are some physiological situations in which the individual may experience headache,
such as to sleep, to cough and to love. In the rst situation, "to sleep", the patient does not
have headache when awake, but is awakened by pain during sleep; in the second, the act
of "to cough" is a trigger for the onset of pain and nally, "to love," here, meaning sexual
intercourse, can be a headache trigger.
Objective
To review the epidemiological, pathophysiological aspects and therapeutic management of
headaches that arise when sleeping, coughing and having sexual intercourse.
Method
A narrative review of literature including case reports and clinical trials were carried out. The
articles were systematically obtained and assessed by the authors.
Results
Three primary forms considered rare were identied: hypnic headache, primary cough
headache and primary headache associated with sexual activity. Hypnic headache occurs
only during sleep, predominantly in women after 50 years of age. It was described in 1988
by Raskin, and has a prevalence ranging from 0.07% to 0.22%. Primary cough headache
is triggered by coughing or another Valsalva maneuver and is more common in men over
40 years of age. It was rst described by Jules Tinel and has a prevalence of 0.4% to 1.2%.
Primary headache associated with sexual activity occurs during sexual intercourse. It is more
frequent in men after 40 years of age. It was described in the second century of the Christian
era, by the Persian physician Avicenna. Its prevalence ranges from 0.9% to 1.6%.
Conclusion
Primary headaches in the "to sleep", "to cough", and "to love" group are rare. They predo-
minate in men, after 40 years of age, are of short duration, can be primary or secondary
and have a therapeutic response to indomethacin.
R. P. Silva-Néto
Federal University of Delta of Par-
naíba, Avenida São Sebastião,
2819/Fátima, Parnaíba, Piauí,
64001-020, Brazil, Tel. + 55
863221-9000.
netoesperantina@terra.com.br
Edited by:
Marcelo Moraes Valença
Keywords:
Headache
Sleep
Cough
Sexual activity
Indomethacin
Valsalva maneuver
Precipitating factors
Received: October 2, 2021
Accepted: October 9, 2021
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“To sleep”, “to cough” and “to love’: Uncommon primary headaches
Introduction
T
here are some physiological situations in which the individ-
ual may experience headache, such as to sleep, to cough
and to love. In the rst situation, "to sleep", the patient does
not have headache when awake, but is awakened by pain
during sleep;
1,2
in the second, the act of "to cough" is a trigger
for the onset of pain;
3
and nally, "to love," here, meaning
sexual intercourse, can be a headache trigger.
3
In ICHD-3, in the group of primary headaches, primary
cough headache, primary headache associated with sexual
activity and hypnic headache are described, with well-
established diagnostic criteria.
4
Despite being called primary
headaches, they can be secondary to other pathologies,
requiring further investigation.
In this review, we will discuss these unusual forms of headache.
Its diagnostic criteria, pathophysiology, differential diagnosis
and treatment will be addressed.
Headaches that occur during sleep
Some headaches occur during sleep or on awakening.
5,6
They are distributed into two groups, primary and secondary,
as shown in Table 1.
Table 1. Distribution of headaches that occur during sleep
ICHD-3 code Classification
Primary
1.1 Nocturnal migraine
3.1 Cluster headache
3.2 Paroxysmal hemicrania
3.3 SUNCT and SUNA syndrome
3.4 Hemicrania continua
4.9 Hypnic headache
Secondary
5.2 Persistent headache attributed to traumatic injury to the head
6.3 Headache attributed to unruptured vascular malformation
6.4.1 Headache attributed to giant cell arteritis
7.1.4
Headache attributed to intracranial hypertension secondary to
hydrocephalus
7. 4 Headache attributed to intracranial neoplasia
7.6.2 Post-ictal nocturnal headache
8.2 Medication-overuse headache
10.1.4 Sleep apnoea headache
10.3 Headache attributed to arterial hypertension
10.3.1 Headache attributed to phaeochromocytoma
10.7
Headache attributed to other disorder of homoeostasis
(hypoglycemia)
12 Headache attributed to psychiatric disorder
The rst group includes nocturnal migraine and the following
trigeminal-autonomic headaches: cluster
headache, paroxysmal hemicranias short-lasting unilateral
neuralgiform headache attacks with cranial autonomic
injection and tearing (SUNCT) and hemicrania continua.
These headaches have similarities in some symptoms and
all have good therapeutic response to lithium carbonate.
7
The second group contains the majority of nocturnal
headaches. Among secondary headaches, there are
headaches attributed to several causes, such as subdural
hematoma, non-ruptured vascular malformation, giant
cell arteritis, communicating hydrocephalus, intracranial
neoplasia, post-ictal nocturnal headache, medication-
overuse headache, sleep apnea headache, nocturnal
arterial hypertension, pheochromocytoma, etc.
1,5,8
Nocturnal migraine. In migraine patients, particularly
without aura, headache attacks can occur at any time of the
day, including during the night, after sleep onset or when
waking up.
9
Nocturnal migraine
has not yet been sufciently validated
by scientic studies. However, the experts' experience
suggests the existence of a primary headache that arises
during sleep or upon awakening and fullls diagnostic
criteria for migraine without aura and not for other primary
headaches.
10
Additional scientic evidence are still
required for it to be formally accepted and included in the
classication of headaches.
10,11
Due to the use of lithium in cyclic evolution pathologies,
Raffaelli started to test it in nocturnal migraine. These patients
had an absolute therapeutic response to lithium carbonate,
at a dose of 300 to 600 mg/day, in a single dose at night,
as in the case of hypnic headache.
11
Trigeminal autonomic cephalalgias
. All of these in this
group can occur during sleep and awaken the patient,
the most studied being cluster headache, whose nocturnal
crises range from 50% to 60%.
12
They are accompanied
by autonomic manifestations and have specic treatments,
such as cluster headache, which is responsive to oxygen and
sumatriptan; and paroxysmal hemicrania and continuous
hemicrania that is treated with indomethacin.
4
Hypnic headache
. This headache always occurs during
sleep, causing the patient to wake up.
4,13
It is the real
sleep headache. It is a rare primary recurrent headache
with a prevalence ranging from 0.07% to 0.22%.
1
There is
predominance in women (69% versus 31%) and characteristic
of middle age and old age. There are no cranial autonomic
symptoms or restlessness and responsiveness to lithium, at a
dose of 300 mg to 600 mg, at bedtime.
Hypnic headache was rst described by Raskin, in 1988.
13
This author published a series of cases that described a new
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Souza WPO, Fortes YML, Silva-Néto RP
“To sleep”, “to cough” and “to love’: Uncommon primary headaches
type of headache that affected elderly patients during sleep.
In all patients, the headache resolved with the use of lithium
carbonate.
13
It is believed that there is a hypothalamic dysfunction,
especially due to the decrease in the activity of the
suprachiasmatic nucleus, which is the biological clock
responsible for the circadian rhythm. This nucleus has a
functional proximity to the raphe and pineal gland nuclei. As
a result of the decrease in the activity of the suprachiasmatic
nucleus, there is a decrease in the release of serotonin and
melatonin. Decreased serotonin release leads to decreased
modulation of the suprachiasmatic nucleus; and decreased
melatonin secretion, leading to decreased modulation of
nociceptive circuits. This pathophysiology explains why
lithium improves hypnic headache. Lithium increases
serotoninergic neurotransmission in the hypothalamus and
melatonin secretion.
6,14-17
The successful treatment of hypnic headache, both
abortifacient and prophylactic, is based on case reports or
series, as no randomized clinical trial has been performed.
Due to the short duration of pain, it is difcult to administer
an abortive treatment. Despite this difculty, some drugs
have been tested, even in a few patients, and the results
are not encouraging. The best responses were with caffeine,
alone or associated with analgesics. Prophylactic treatment
is based on the continuous use of drugs, before bed, to
prevent the occurrence of headache attacks during sleep.
Lithium is still the drug of choice.
1
Secondary nocturnal headaches resolve with removal of the
underlying cause and most have a diagnostic biomarker.
Below, we will make brief comments about them.
Sleep apnea headache is characterized by occurring
on awakening with duration of less than four hours. Its
diagnosis is made through polysomnography.
4
Headache
attributed to giant cell arteritis appears at any time of day,
but worsens during the night and is associated with other
systemic clinical manifestations.
18
Usually, in patients with
chronic subdural hematoma, the onset of headache is at
night or upon awakening and worsens in the morning.
19
Headache attributed to intracranial neoplasia has
characteristics of migraine or tension-type headache,
but occurs at night or upon awakening in association
with vomiting.
20
Patients with epileptic seizures during
sleep may experience post-ictal nocturnal headache.
4
Headache is the main symptom of communicating
hydrocephalus and is characterized by the daily occurrence,
usually when waking up.
21
Headache attributed to
pheochromocytoma occurs during the night or as soon as
the patient wakes up.
22
There is a case report describing
nocturnal headache in a patient with hypoglycemia.
23
Headaches that occur during coughing
Cough is a defense reex of the airways under physiological
conditions, but it can be part of the clinical picture of several
pulmonary, cardiac and gastrointestinal diseases. There are
three relationships between cough and headache: 1) Cough
is associated with headache, for example, in pulmonary
infectious conditions; 2) Cough can worsen headache, as
in migraine; and 3) Rarely, cough can trigger headache
attacks.
4
Headache triggered by cough was rst described in
1932 by the French physician Jules Tinel (1879-1952) and
was considered an alarming symptom. In 1956, Charles
Symonds (1890-1978) reported 21 patients with cough
headache, without any intracranial lesion, now known as
primary cough headache.
24
However, this headache can be
primary or secondary.
Figure 1. Pathophysiology of hypnic headache.
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“To sleep”, “to cough” and “to love’: Uncommon primary headaches
In the primary form, there is no intracranial lesion. It is a rare
headache, occurring in 0.4% to 1.2% of the population.
25-27
It is more common in men after age 40. It is characterized
by being bilateral, having a dull character and of moderate
intensity. The onset of pain is sudden, lasting from one
second to hours. It is caused by coughing or another
Valsalva Maneuver.
4
Diagnosis of primary cough headache
requires the absence of any other intracranial pathology.
The secondary form is much more frequent and is present
in approximately 11% to 59% of the population. It is due
to several neurological diseases, such as Chiari type I
malformation, platibasia, chronic subdural hematoma,
arachnoid cyst, dermoid tumor, and meningioma, among
others.
28
The neuroimaging exam is essential for its diagnosis.
From a pathophysiological point of view, cough headache
arises from increased intracranial pressure [Fig 2]. During
coughing, there is an increase in intrathoracic pressure.
Consequently, two situations occur: 1) inhibition of venous
return from the internal jugular veins, causing an increase
in intracranial venous pressure; and 2) the increase in
intrathoracic pressure is transmitted to the epidural veins,
leading to compression of the spinal canal dura mater, with
increased pressure in the spinal canal. These two situations
culminate in increased intracranial pressure, resulting in
headache.
29
Figure 2. Pathophysiology of primary cough headache.
Treatment of the secondary cough headache is by removing
the underlying process. In primary cough headache,
indomethacin is still the most consistent treatment. This drug
was rst used to treat cough headache in 1981 in a double
blind, placebo-controlled study in patients resistant to other
preventives. There was a therapeutic response between one
and four weeks and the effect was sustained through 18
months of follow-up.
30
The dose of indomethacin ranges from 25mg to 250 mg a
day.
30
Other drugs such as acetazolamide and propranolol
are cited.
31,32
Some studies report dural puncture and non-
invasive vagus nerve stimulation as alternative treatments.
25,33
Cough headache has a good prognosis, as it is a self-limited
condition, lasting months to a few years. The therapeutic
response occurs within a few weeks.
Headache that occurs during sexual intercourse
“To love” can cause headaches. The expression “to love”
here means sexual intercourse, either with another partner
or during masturbation. This unusual headache was rst
described in the century II, after Christ, by the Persian
physician Avicenna and is considered one of the oldest
headaches.
24
It is classied as primary or secondary to an
underlying process of other pathologies.
Diagnostic criteria for primary headache associated with
sexual activity are described in ICHD-3. It only occurs
during sexual activity. The onset of pain occurs with sexual
excitement, it increases in intensity at the moment of orgasm,
lasting from one minute to 24 hours.
4
According to recent studies, primary headache associated
with sexual activity predominates in middle-aged men and
its prevalence ranges from 0.9% to 1.6%.
34-36
However, the
true prevalence of this headache is not known, due to the
scarcity of studies and difculty for patients to express their
symptoms out of embarrassment.
The pathophysiology of primary headache associated with
sexual activity is unknown, but some authors believe that it is
due to sympathetic activation.
37
In sexual physiology, there
is participation of the sympathetic and parasympathetic
autonomic nervous system [Fig. 3]. During arousal and
erection there is parasympathetic activation; and in
ejaculation and orgasm there is sympathetic activation.
There is excessive release of catecholamines, leading to
craniocervical venous stenosis during sexual activity, which
would culminate in pain. This venous stenosis was seen in
63% of craniocervical venographs.
38
For this reason, sexual
headache is responsive to beta-blockers.
Figure 3. Pathophysiology of primary headache associated with
sexual activity.
Despite being considered a primary headache, all patients
who present this headache must necessarily undergo
neuroimaging tests to exclude secondary causes. It may
be a symptom of an underlying process of intracranial
pathologies. In the differential diagnosis, subarachnoid
hemorrhage, rupture of cerebral aneurysm, cervical arterial
dissection and arteriovenous malformation should be
considered.
3,37,39
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“To sleep”, “to cough” and “to love’: Uncommon primary headaches
After the onset of headache, the patient will need an acute
treatment and the most used drugs are indomethacin and
triptans.
37,40
There is also preemptive treatment, in which
indomethacin is used 30-60 minutes before sexual activity.
In 40% of patients, the pain resolves if the patient stops
sexual activity before reaching orgasm.
3
In prophylaxis, the most consistent treatment is beta-blockers,
which are used in the same dose as for migraine prophylaxis.
Prophylactic treatment is indicated when the patient has
more lasting headache attacks and with a tendency for the
disease to become chronic. Duration of treatment should be
3 to 6 months.
37,41,42
Conclusion
We conclude that primary headaches in the "to sleep", "to
cough", and "to love" group are rare. They predominate in
men, after 40 years of age, are of short duration, can be
primary or secondary and have a therapeutic response to
indomethacin
Contribution authors: All authors had the same contribution.
Funding: No.
Conflict of interests: The authors report no conict of interest.
Wallyson Pablo de Oliveira Souza
https://orcid.org/0000-0003-3122-9484
Yasmine Maria Leódido Fortes
https://orcid.org/0000-0001-9642-0330
Raimundo Pereira Silva-Néto
https://orcid.org/0000-0002-2343-9679
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