4.3.1 Probable primary headache associated with sexual activity

A 50-year-old librarian describes a fourth episode of head pain, occurring in relation to sexual activity with her husband over the past eight months. In each instance the pain has been present from early on, then abruptly intensified for a brief moment right at the point of orgasm, before easing into a persistent, low-grade ache that has, each time, taken slightly more than three days to fully settle. She is quite clear that the pain has at no point been severe, describing it as tolerable and manageable with paracetamol. She has had to withdraw from intimacy on every occasion as soon as the ache flared. There has been no vomiting reported, no sensitivity to sound, and no visual aura of any kind. Her only regular medication is levothyroxine for an underactive thyroid.