Ask Dr. Bob

I sometimes get severe headaches at orgasm. It is worrying my husband and me, too! Is there something wrong?

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.

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.

I just stumbled onto your column last week and found it to be very interesting and well-written. My question to you is not so much a professional question as it is a "question of profession."

If you have any time, your input, advice or even amusing anecdotes would be tremendously appreciated. I feel that this vacillation is paralyzing my motivation altogether. I am driven toward each career, and yet feel that I must make a choice or forever wallow in compromise as I am doing now.

The most overlooked consideration in giving career advice is the passage of time. People change. So the longer the professional training period, the greater should be your certainty, which is an impossible task given that what sounds great at 24 might seem like a terrible mistake at 50.

Unlike many trades, medicine allows little lateral transfer of skills (although perhaps surgeons can become butchers). Sure, you can switch from research to practice to hospital administration to medical journalism, but the training is much more confining than studying law, journalism or art. Before making any decision, take some time for introspection. Imagine yourself at various ages. Talk to people in different phases of the profession.

More than ever before, being a physician requires a commitment to personal values that may not be adequately rewarded by the general public. Spending more time with your patients won't endear you to your clinic administrator.

But then, slaving over a sentence won't necessarily bring better reviews or book sales. The commercial aspects of medicine and fiction writing are somewhat similar. Unless you are a super-specialist or a blockbuster writer, your income will not compare with that of MBAs or day traders. In both medicine and writing, pursuit of excellence is its own reward.

Regardless of managed care, future care or whatever else is coming down the pike, the thing about medicine that will never disappear is its wonderful sense of drama. Life and death are immune to the vagaries of HMOs. If you really like personal engagement, the nitty-gritty of heartbreak, grief and joy, there is no more rewarding profession. But you must see this as a calling, a commitment stronger than any sense of a life sacrificed or outside opportunity missed. More than ever, going into medicine -- to be a satisfactory choice -- is like choosing to be a man of the cloth.

This is the tricky part about career decisions -- knowing what, for you, is the best balance between internal and external rewards. Much of the dissatisfaction felt by today's physicians stems from their comparing their own salary, praise, status and working conditions with those of business tycoons, software developers and mega-lawyers. Comparison tends to generate envy and bitterness. What you are not privy to at your age is the converse, the underlying sense of insubstantiality that I hear and see among so many of the so-called successful business folk.

Writers have a similar dilemma. The best literature is seldom recognized in today's celebrity- and bottom-line-driven publishing world. Writers can take comfort that they are pursuing their art. But, by the same argument, doctors, even though bombarded by a battery of social forces, can still feel pleasure in their individual patient relationships and accomplishments.

Now for a very politically incorrect comment: Above all, what you need to decide is whether you have a true talent for writing. Without talent, most are best suited for a structured work life, one in which they are not constantly challenged with a blank page or canvas. Routine is God's gift to the unimaginative. Conversely, the artistically gifted tend to be restless, constantly seeking new form and structure in their work.

My writer friends, like myself, might feel envy at the stack of Stephen King or Tom Clancy books in front of Office Depot and K-Mart, but that isn't why we write fiction. The rewards are internal. Even if I were able to figure out a formula for mega-success, I would abandon it for the next book. For me, life is about exploration, not repetition. Which is why I would have made a very poor general practitioner. And why, during this age of brain speculation, neurology has been so much fun.

When I was considering taking up novel writing, I had lunch with a local psychiatrist who was also a novelist. His sage comment: "When I am at a medical meeting, I am glad I am a writer. When I am at a writers' conference, I say, 'Thank God I'm a doctor.'"

Do both and don't look back.