Headache © 2009 the Authors Journal compilation © 2009 American Headache Society ISSN 0017-8748 doi: 10.1111/j.1526-4610.2009.01479.x Published by Wiley Periodicals, Inc. Clinical Notes Recurrent Coital Headache Associated With an Unruptured Carotid Saccular Aneurysm head_1479 1232..1240 Juan M. Uterga, PhD; Miguel A. Gonzalez de Garay, PhD; Itziar Ortiz de Luna, PhD; Juan B. Uribarri, PhD We report the case of a 48-year-old woman whose recurrent coital headache ceased following intracranial internal carotid artery aneurysm embolization. Key words: secondary headache, headache associated with sexual activity, carotid aneurysm Abbreviations: HASA headache associated with sexual activity (Headache 2009;49:1232-1239) Address all correspondence to J.M. Uterga, Hospital of Basurto, E-48013 Bilbao, Spain. sions. When she arrived at the hospital, 2 hours later, the symptoms had disappeared and the examination was normal. During the previous 2 months, she had presented other 5 episodes of headache similar to the one described here, and so intense she would not insist on reaching orgasm; not all the sexual activity was associated with headache, only the one involving the highest excitation. These episodes used to last 15 minutes, in one case 3 hours, and there were never any accompanying symptoms. Personal background was uninteresting, except that she was drinking more alcohol during the previous months, and she would occasionally sniff cocaine. Cerebrospinal fluid analyses, at admission and 48 hours later, were normal (biochemistry, cultures, viral serology, herpes virus and Mycobacterium tuberculosis polymerase chain reaction, and malignant cell cytology). On the electroencephalogram, left frontal irritation paroxysms were detected. The cranial computed tomography scan was normal. However, in a cranial magnetic resonance imaging with angiography and a complete digital brain arteriography, small ischemic lesions were detected, few in number and with chronic aspect, located at the white substance of both brain hemispheres, as well as a saccular Accepted for publication April 27, 2009. Conflict of Interest: None Headache associated with sexual activity (HASA) is an infrequent form of primary headache.The presence of an intracranial arterial dissection, an arteriovenous malformation, hydrocephalus, brain infarction, and intake of drugs has been associated with HASA. We present a case associated with an intact aneurysm in the intracranial internal carotid artery. CASE A 48-year-old woman was admitted after suffering an alteration of consciousness and intense headache during sexual intercourse. When she reached orgasm, she suddenly felt extremely intense pain in both temples, which forced her to stop the activity; the pain persisted with a decreasing intensity until it disappeared 30-60 minutes later. Moreover, she had a sensation of unreality of her surroundings, a doubtful diplopia, decreased consciousness, and convulFrom the Neurology Department (J.M. Uterga), Radiology Department (M.A.G. de Garay), Emergency Department (I.O. de Luna), Neurosurgery Department (J.B. Uribarri), Basurto Hospital, Bilbao, Spain. 1232 Headache 1233 Figure.—The digital brain arteriography shows a saccular aneurysm in the cavernous portion of the right internal carotid, immediately proximal to the origin of the ophthalmic artery, and 3.1 ¥ 3.3 mm in diameter (A); the same aneurysm after its complete occlusion (B). aneurysm in the cavernous portion of the right internal carotid artery (Figure A). Afterwards, the aneurysm was filled with 3D Omega Standard and Ultra Soft Helical (Figure B). After this episode, the patient has not had any recurrence. make us think the patient had an episode of sentinel HASA in a still intact carotid aneurysm. In summary, in patients with atypical HASA, clinicians should be aware that headache may be a presenting manifestation of an intracranial internal carotid artery aneurysm. DISCUSSION The patient had an episode of HASA, associated with the finding of an aneurysm in the right intracranial internal carotid artery, which disappeared after its therapeutic embolization. At first, it could be argued that the aneurysm was not the cause, but coincidental, and occluding it therapeutically had no clinical effect, as primary HASA patients usually remain asymptomatic after a single headache episode.1,2 However, patients with intact intracranial aneurysms have been reported to have frequent headache, and it can be treated with surgical or radiological treatment of the aneurysms.3,4 Also, the final rupture of brain aneurysm is known to be heralded by an explosive headache.5 Several pathophysiological mechanisms have been proposed to explain this type of headache, among them the thrombosis or local expansion of the aneurysm, interior bleeding of its wall, and meningeal inflammatory reaction around it.3,5 The headache presented by the patient was of explosive type;5 moreover, the last episode was accompanied by a visual disorder and convulsion, which is not typical of the primary form of HASA;6,7 these, together with the above, REFERENCES 1. 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