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North Carolina Comprehensive Headache Clinic - Raleigh, NC

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Our Facility

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North Carolina Comprehensive
Headache Clinic

2501 Atrium Drive, Suite 400
Raleigh, NC 27607
Phone: (919) 781-7423

Office Hours:
Monday - Thursday: 8am to 4pm

Causes of Headache


The International Headache Society Classification  

We use the headache classification developed by the Internal Headache Society (IHS).  

Follow this link to the IHS, and use this classification as a means of further research on causes of headache:


     There are very good articles on Wikipedia for each rare headache subtype listed in the IHS headache classification.  We review these articles regularly for accuracy and recommend them to our patients.  There are good articles on cluster headache, trigeminal neuralgia, hypnic headache, hemicrania continua, paroxysmal hemicrania, benign intracranial hypertension (“pseudotumor cerebri”), spontaneous intracranial hypotension, reversible cerebral ischemia (“thunderclap headache”), temporal arteritis, and others.  



Emergency causes of headache include:



1) Aneurysm rupture (sudden explosive headache)


2) Brain tumor (progressive weakness on one side, seizure)


3)  Meningitis or Encephalitis (headache, fever, confusion)



Chronic Infections


     Among the large number of patients we evaluate, a very few will have undetected chronic infection of the coverings surrounding the brain, such as tuberculosis, aids, or fungal infections.

In North Carolina we see Rocky Mountain Spotted Fever, Lyme disease, chronic mononucleosis, and other undetected systemic infections.


Toxic exposure


  We see toxic disorders such as carbon monoxide, mold, and heavy metal poisoning.


Genetic diseases


     Some genetic diseases are associated with headache and an increased risk for stroke, such as blood clotting disorders and Cadasil syndrome.


     Those with Marfan’s syndrome (tall people with an arm span greater than their height) are at risk for early death from sudden rupture of a weakened blood vessel unless diagnosed and treated.


     Fibromuscular dysplasia is a condition affecting blood vessels in young people that may be associated with headache.


Congenital malformations


Benign brain cysts may rarely cause headache through compression of surrounding structures (arachnoid cysts,  pineal cysts).  Arnold-Chiari malformation and other malformations of the base of the brain and skull may be associated with headache.  Some patients with a usually benign cardiac condition called patent foramen ovale (“PFO”) may have an increased risk for migraine and stroke.


Brain tumors


While most brain tumors and other masses in the brain are easily detected by CT or MRI, rare infiltrative tumors of the brain such as lymphoma, and more common very small tumors of the pituitary, may cause headaches without changes on MRI. Brain aneurysms may require special studies to detect.


Hormonal dysregulation


Hormonal problems are commonly associated with onset of new headaches. The patient with a hormonal problem will sometimes have headache as the primary symptom. Women often already know that they have a hormonal problem underlying their headache. Besides imbalances in estrogen, progesterone, and testosterone,  other hormonal problems may cause headache, such as thyroid, adrenal, growth hormone, or parathyroid dysfunction.


Sleep disorders


Sleep apnea may typically cause a morning headache and daytime drowsiness, but if not detected and treated may lead to medical complications over time.


Inflammatory disorders


     Systemic lupus erythematosis, polyarteritis nodosa, temporal arteritis, and other inflammatory conditions may cause headache.


“Normal MRI”


Almost all of the problems above will have a "negative MRI".


Sometimes, patients receive an MRI to investigate headache, but the MRI is not done in a way that will detect the problem. In some headache conditions, it is necessary to administer a contrast agent (gadolinium) by IV to detect such conditions as low-pressure headache or cancer of the meninges. In other cases, specific enlarged MRI views of the pituitary with contrast agent are necessary to detect a pituitary tumor. In others, clotting of the veins in the brain or inflammation of the arteries can only be detected by an MRI arteriogram or venous angiogram. So, a "negative MRI" may be misleading.


Headache-Associated Medical Illness


If you have multiple symptoms in addition to headache, we consider a holistic approach to diagnosis and treatment. Conditions commonly occurring with headache include fibromyalgia, chronic fatigue, depression, anxiety, insomnia, irritable bowel syndrome, dizziness or vertigo, sinus symptoms, and neck pain.


Illness Caused by Headache Treatment


     Diseases caused by headache treatment include  liver failure or bleeding with Depakote and kidney stones or sudden glaucoma with Topamax. Beta blockers (Inderal and Toprol) and antidepressants can cause sexual dysfunction or loss of interest in sex. Almost all medications for headache can cause sedation and put the patient at risk for automobile accidents.


     Antidepressants and anti-nausea medications may rarely produce severe psychiatric reactions such as suicidal feelings or sudden urges to self-injury. Rarely, allergic and anaphylactic deaths occur with aspirin and other pain medications. There is a very small heart attack risk in patients with undetected heart disease who take Imitrex or one of the other triptans.


Headache Treatment and Long Term Disease Risk


The most common health risk caused by medication for headache treatment is weight gain. Depakote and Elavil (amitriptyline) commonly produce this side-effect. It is important to consider the history of cardiac risk factors in the patient and in the family before using such agents. This is just as important in the twenty year old as the fifty year old- actually, more so! The issue is the risk of heart attack and stroke many years from now. Weight gain is a serious, frequent, and often unnecessary, side effect.


Another health risk caused by medication for headache treatment is high blood pressure. Recently, cardiology consensus has moved to a much lower standard for what is considered a "safe" blood pressure for the long term.  Some of the antidepressants used to treat headache raise blood pressure. Those antidepressants most beneficial for headache all have an effect of increasing norepinephrine, a brain neurotransmitter which is directly related to modulation of pain. Unfortunately, these medications may raise blood pressure as well.


Effexor, Elavil, and Pamelor very commonly have these side effects, as do the newer SNRI (Seratonin-Norepinephrine-Reuptake Inhibitor) antidepressants such as Cymbalta.  Since the new blood pressure recommendations are so low, even a small increase in blood pressure caused by medication may put a patient into the "pre-hypertension" category. For a young patient facing years of medication, this is a serious matter.


Some headache medicines can cause osteoporosis. Topamax, for example, was known to sometimes cause significant metabolic acidosis and thus, fatigue, when the drug was first approved for use by the FDA. Based on the effect of acidification of the urine, however, we remain alert as to whether there is an effect of Topamax on bone formation.  If the long term administration of Topamax is necessary, we may follow bone density yearly.