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The first time I heard a patient complain about headaches during sex, I began asking questions about her marriage, thinking the problem was psychological and that she wanted a letter from her doctor excusing her from intimacy.

But the patient's marriage was more solid than my medical skills. The woman not only enjoyed sex, she loved it. The problem wasn't during all sex; it was limited to the moment of orgasm. My further faulty reasoning: If the problem wasn't psychological, it must be mechanical. I questioned her about various positions. The woman blushed, then told me the most vivid details.

"Maybe you shouldn't have your legs in the air, hang your head over the side of the bed and do it upside down," I said. She went home with a new game plan: missionary position only. She returned in two weeks. The headaches were the same: severe throbbing occurring right at the onset of orgasm. They tended to last for 10 to 15 minutes and then resolve.

We reconsidered the psychological implications, searched for foreplay's subliminal messages and even used the word-association method. Perhaps there was a hidden meaning in the phrase "pounding headache." The woman left my office in tears, convinced that she was screwy in the head and worried that she had some unconscious disdain for sex, her husband and the world in general.

Mea culpa. A thousand apologies to that patient. A couple of years after that encounter I came across a journal article describing orgasmic migraine. The headaches weren't psychological or mechanical, but rather a physiological disorder complete with a frequent family history.

Ask Dr. Bob Dr. Robert Burton, who is a neurologist and novelist, answers health questions every Monday in Salon Health & Body. Please e-mail your queries to him at AskDrBob@ salon.com.

Orgasmic migraine is now a well-recognized entity of high-intensity, often throbbing headache that begins during sexual arousal, both with and without a partner, culminates in a splitting headache at orgasm and then relatively quickly subsides. It is seldom associated with the other symptoms of migraine such as nausea, vomiting and photophobia. And it is rarely associated with any serious underlying pathology such as an aneurysm or arteriovenous malformation of the brain. It is more common in men than women. It tends to occur in episodes lasting a few weeks to a few months, and then subsides only to recur without specific provocation.

I suspect that many people have had a paroxysm of coughing during which they have a sudden sharp headache that lasts a few seconds. This is a migraine variant referred to as "cough headache." Similarly, there are those who get bad headaches during exertion. The mechanism is probably the same. In some respects the orgasmic migraine is similar to these forms of benign vascular headache. The prevailing theory suggests that migraine is caused by neurogenic inflammation of brain-stem structures, especially the portion that controls the nerves and vasculature of the face.

The headaches often can be treated preventively with beta blockers and calcium-channel blockers. The results are good; in any case, the headaches tend to resolve on their own, regardless of the treatment.

The point to remember: The headache is benign and has no Freudian implication regarding sexuality. So let your lover, not your headache, get you down.

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