“The headache he can’t talk about”

Coital (primary sexual) headache is a recognised, benign, treatable condition — a bilateral throbbing headache that builds with arousal and peaks at orgasm — but it sits beside a lethal mimic: a FIRST or thunderclap-quality sexual headache (instant explosion to maximum) can be a sentinel subarachnoid haemorrhage or RCVS and is an emergency. The discriminator is the onset (gradual build vs instant explosion) and whether it is the first-ever attack. The whole consultation hinges on a skill rarely tested elsewhere: making it safe for a mortified patient to disclose a sexual symptom through normalising, permission-based questioning — without which he leaves with "just a tablet" and an undiagnosed problem. The hidden agenda is double: terror of a brain aneurysm (family history) and a marriage damaged because his avoidance of sex has been misread as rejection. Reassure accurately (state the emergency rule honestly — NICE NG228 for thunderclap onset), seek neurology advice on imaging (NICE CG150 lists exertion-triggered headache among features prompting consideration of investigation or referral, and his brother had an aneurysm), treat (propranolol or pre-coital triptan/indometacin, off-label, doses per BNF; confirm the BP with home readings, NICE NG136), and — crucially — help him break the silence with his wife.