Shilajit-associated orgasmic thunderclap headache: A probable case of reversible cerebral vasoconstriction syndrome managed with nerve blocks

INTRODUCTION

Thunderclap headache triggered by sexual activity presents a diagnostic challenge, as it may represent either a primary headache associated with sexual activity (PHASA) or a manifestation of secondary causes such as reversible cerebral vasoconstriction syndrome (RCVS) or subarachnoid hemorrhage.^1,2 RCVS is characterized by recurrent severe headaches and reversible multifocal cerebral vasoconstriction and is often associated with exposure to vasoactive substances.³ Although sphenopalatine ganglion (SPG) and pericranial nerve blocks are established treatments for migraine, their role in the management of thunderclap headache triggered by sexual activity remains poorly described.⁴ We report the first known case of orgasmic thunderclap headache associated with Shilajit use and managed with regional nerve blocks.

CASE PRESENTATION

A 46-year-old man with obesity and no prior history of headaches presented with headaches triggered by sexual climax. Symptoms began six days after initiating daily Shilajit supplementation. The first episode occurred during sexual intercourse and was characterized by a sudden-onset, bilateral frontal headache that reached maximal intensity (10/10) at orgasm. He described the sensation as though his “head would burst,” causing him to stop sexual activity. He rolled off his partner and remained in a crouched position due to the severity of the pain. There were no associated focal neurologic deficits, nausea, or vomiting. The headache partially improved with ibuprofen but worsened the following day during mild exertion (while removing a lid from a food container), prompting presentation to the emergency department. A non-contrast head CT was unremarkable, and he was discharged.

A persistent mild baseline headache (3/10 intensity) subsequently developed. On day nine, a second episode of an identical orgasm-triggered headache occurred, again preventing ejaculation and prompting hospital admission. Repeat neuroimaging, including non-contrast head CT, CT angiography, and brain MRI, revealed no evidence of intracranial hemorrhage, aneurysm, vascular malformation, or vasoconstriction. Lumbar puncture revealed findings consistent with a traumatic tap, with the red blood cell count(RBC) decreasing from 112,738/µL in tube 1 to 244/µL in tube 3, effectively excluding subarachnoid hemorrhage.

Blood pressure remained in the low-normal range (approximately 110/70 mmHg), limiting the use of calcium channel blockers. Based on the explosive, climax-interrupting headaches, recurrence with mild exertion, and temporal association with initiation of Shilajit supplementation, a probable reversible cerebral vasoconstriction syndrome (RCVS)-like syndrome was diagnosed.

On day 10, the patient underwent a transnasal sphenopalatine ganglion (SPG) block in combination with bilateral greater occipital, lesser occipital, and supraorbital nerve blocks. His baseline headache resolved immediately following the procedure. Shilajit was discontinued. Within 48 hours, he resumed sexual activity without recurrence of thunderclap headache and was able to achieve normal orgasm. He remained asymptomatic at follow-up.

DISCUSSION

This case illustrates the diagnostic challenge of distinguishing primary from secondary orgasmic headache.¹ The pain’s thunderclap onset and occurrence at climax suggested an underlying vascular etiology rather than a benign primary headache disorder. Recurrence of symptoms with even mild Valsalva-related exertion further supported a diagnosis of reversible cerebral vasoconstriction syndrome (RCVS) over primary headache associated with sexual activity (PHASA).¹ Although initial neuroimaging was unremarkable, angiographic abnormalities in RCVS may be delayed in appearance or confined to distal vessels.³ Therefore, the clinical context—including the trigger, thunderclap presentation, and recurrence with exertion—remains essential for accurate diagnosis.

Shilajit, a nutraceutical containing fulvic acid and minerals, has been purported to increase testosterone levels and may enhance sympathetic activity. This case expands the growing list of nutraceuticals associated with reversible cerebral vasoconstriction syndrome (RCVS).³ Previously reported agents include Hydroxycut⁵ and eucalyptus vapor.⁶

First-line treatment for RCVS typically involves calcium channel blockade,³ but its use was precluded by the patient’s low-normal blood pressure. The sphenopalatine ganglion (SPG) plays an important role in regulating cerebral vascular tone through parasympathetic pathways.⁴ Blockade of the SPG, along with pericranial nerve blocks, may stabilize neurovascular dysfunction. The rapid clinical improvement observed in this case suggests nerve blocks may represent a potential therapeutic alternative for hemodynamically sensitive patients; however, larger studies are needed.

CONCLUSION

Shilajit may represent a novel trigger for probable reversible cerebral vasoconstriction syndrome (RCVS) presenting as an orgasmic thunderclap headache. In our case, combined sphenopalatine ganglion (SPG) and pericranial nerve blocks provided effective symptom control when standard vasodilators were contraindicated because of low-normal blood pressure. Clinicians evaluating patients with thunderclap headache should specifically inquire about the use of supplements and nutraceuticals as potential precipitating factors.

REFERENCES

1. Singhal AB, Hajj-Ali RA, Topcuoglu MA, et al. Reversible cerebral vasoconstriction syndromes: analysis of 139 cases. Arch Neurol. 2011;68(8):1005–12.
2. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211.
3. Ducros A. Reversible cerebral vasoconstriction syndrome. Lancet Neurol. 2012;11(10):906–17.
4. Tolba R, Weiss AL, Denis DJ. Sphenopalatine ganglion block: a review. Ochsner J. 2019;19(1):32–7.
5. Cvetanovich GL, Juthani RG, Mack WJ, et al. Reversible cerebral vasoconstriction syndrome in a patient taking Hydroxycut. J Med Case Rep. 2011;5:548.
6. Lapid D, Abbasi A, Ramakrishnan N, et al. Possible reversible cerebral vasoconstriction syndrome associated with eucalyptus. J Vasc Interv Neurol. 2017;9(5):17–20.

Article citation: Mojumder DK, Temesgen S, Babar S. Shilajit-associated orgasmic thunderclap headache: A probable case of reversible cerebral vasoconstriction syndrome managed with nerve blocks. The Southwest Journal of Medicine. 2026;14(61):103–105
From: Department of Neurocritical Care, Ochsner Medical Center, New Orleans, (DKM). Department of Internal Medicine, Marshfield Medical Center, Marshfield, WI (TS, BS)
Conflicts of interest: none
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