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muscles as deliberate muscular relaxation relieves it. Masters and Johnson observed that "the muscles of the neck contract involuntarily in a spastic pattern" during intercourse .5 The second component, which may follow the first or arise without warning, occurs abruptly at the time of orgasm as a severe occipital or generalised ache, described as explosive or excruciating. The mechanism of this, one of several "thunderclap" headaches described by Wijdicks et al,' is particularly interesting. Such headaches may well be precipitated by an acute pressor response-during orgasm systolic blood pressure increases by 40-100 mm Hg and diastolic pressure increases by 20-50 mm Hg.5 These increases are comparable with those during the paroxysmal headaches caused by phaeochromocytoma,7 which they closely resemble. Occasionally symptoms of cerebrovascular insufficiency may accompany explosive sexual headache. Two young men have had a stroke as a result, one with a brain stem thrombosis3 and the other with infarction of the left cerebral hemisphere.8 Multiple areas of cerebral arterial spasm were shown angiographically in a 30 year old man after a coital headache that exertion had exacerbated.9 Happily, such vascular complications are rare. An association between benign sex headaches and migraine was found in 17 patients followed up by Silbert et al, eight of whom had a history of migraine and five a family history of migraine.'0 Another, rarer type of headache was described by Paulson and Klawans.'I They described three patients with postural headaches after coitus, which were present on standing, eased by lying, accompanied by a low cerebrospinal fluid pressure, and persisted for several weeks. Does physical exertion play any part in these acute vascular headaches? Hippocrates thought so, commenting that "one should be able to recognize those who have headaches from gymnastic exercises, or running, or walking, or hunting, or any other unreasonable labor, or from immoderate venery. "12 The link between venery, moderate or not, and exertional headache has recently been explored by Silbert et al.'0 Eighteen of their 45 patients subject to acute vascular headaches during sexual intercourse had also experienced headaches on exertion. Nine patients described a close link between the two sorts of headache, with one following the other within a few days and a dull generalised headache persisting between the two acute events. During follow up for an average of six years two fifths of them had recurrences of their sex headaches, usually at times of fatigue or stress. In some …