Epidemiology of primary headache associated with sexual activity: A meta-analysis with diagnostic and management considerations.

OBJECTIVE

To assess the prevalence of primary headache associated with sexual activity (PHS) among adults seeking medical help for a headache in clinic-based settings.

BACKGROUND

Primary headache associated with sexual activity is a benign primary headache disorder currently recognized as one of indomethacin-responsive and exercise-related cephalalgias. The epidemiology of PHS among adult patients assessed for headache in the tertiary headache centers is yet to be established.

METHODS

PubMed/MEDLINE, Embase, and ScienceDirect databases were thoroughly searched for observational studies published since January 1, 1988, to November 11, 2024, that reported the relative frequency of PHS among adult patients evaluated for a headache in a clinic-based setting. The additional search of CINAHL (EBSCO) was performed on January 28, 2025, to see whether any relevant articles could have been omitted during the initial search process. The Meta-Analyses of Observational Studies in Epidemiology Guidelines were strictly followed by the study's design. Risk of bias was assessed using Joanna Briggs Institute Checklist for Studies Reporting Prevalence Data. The study's protocol was pre-registered on PROSPERO (ID: CRD42024611082).

RESULTS

Of the original 854 records, 10 research articles (40,702 total individuals, 129 patients with PHS) satisfied all eligibility requirements. The majority of the studies showed a low risk of bias. The prevalence of PHS among adult patients evaluated for a headache in a tertiary care setting was 0.37% (95% confidence interval [CI], 0.17-0.81; 95% prediction interval [PI], 0.02%-6.20%; Luis Furuya-Kanamori index = 0.58) with substantial heterogeneity noted across the studies (I2 = 91.66%). Interestingly, unlike in other primary headache disorders, males have been diagnosed with PHS considerably more often than females (0.28% [95% CI, 0.12-0.63; 95% PI, 0.02%-4.10%] vs. 0.18% [95% CI, 0.09-0.37; 95% PI, 0.02%-1.65%]). Moreover, sex-specific subgroup analysis revealed that PHS was more common among males (1.54%; 95% CI, 0.26-8.57), in comparison to female-specific subgroup (0.61%; 95% CI, 0.22-1.71). The pooled mean age of onset of PHS was 37.35 years (95% CI, 35.35-39.35; 95% PI, 34.01-40.69).

CONCLUSIONS

Our results showed that PHS is a rare headache disorder among adults evaluated for a headache in a clinic-based setting. Furthermore, PHS is more frequent among males and is diagnosed predominantly in males, typically in their mid-30s.