the last few years, New Daily Persistent Headache (NDPH) has been recognized as
a distinct primary headache syndrome. Primary headache disorders are those for
which there is no underlying secondary cause that can be identified. As with
Migraine disease and some other headache disorders, there are several secondary
conditions that can mimic NDPH, so they must be ruled out before a diagnosis of
NDPH can be confirmed. Two conditions in particular that must be ruled out are
cerebrospinal fluid (CSF) leak and cerebral venous sinus thrombosis.
Headache from a spontaneous CSF leak is usually affected by body position, but
the longer it continues, the less apparent that becomes. Therefore, patients may
not think to mention that their headache was, at one point, affected by body
position, and that maybe missed.
What is new daily persistent
The best way to define NDPH is to excerpt that section of the International
International Classification of Headache
4.8 New daily-persistent headache (NDPH)
Previously used terms: De novo chronic headache; chronic
headache with acute onset
- Headache for more than 3 months fulfilling criteria B–D
- Headache is daily and unremitting from onset or from
less than 3 days from onset
- At least two of the following pain characteristics:
- bilateral location
- pressing/tightening (non-pulsating) quality
- mild or moderate intensity
- not aggravated by routine physical activity such as
walking or climbing stairs
- Both of the following:
- no more than one of
phonophobia or mild
- neither moderate or severe nausea nor vomiting
- Not attributed to another disorder
- Headache may be unremitting from the moment of onset or
very rapidly build up to continuous and unremitting pain.
Such onset or rapid development must be clearly recalled and
unambiguously described by the patient.
- History and physical and neurological examinations do
not suggest any of the disorders listed in groups 5–12
(including 8.2 Medication-overuse headache and its subforms),
or history and/or physical and/or neurological examinations
do suggest such disorder but it is ruled out by appropriate
investigations, or such disorder is present but headache
does not occur for the first time in close temporal relation
to the disorder.
In 2002, Li and Rozen conducted the largest study of NDPH to
date based on 56 patients from the Jefferson Headache Center in Philadelphia.
Some interesting points from the study included:
82% of patients were
able to pinpoint the exact day their headache started.
In 30% of the
patients, the onset of the headache occurred in correlation with an
infection or flu-like illness.
38% of the patients
had a prior personal history of headache.
29$ of the patients
had a family history of headache.
laboratory testing was unremarkable except for an unusually high number
of patients who tested positive for a past Epstein-Barr virus infection.
How is NDPH
As mentioned above, other conditions must be ruled out before arriving at a
diagnosis of NDPH. Goadsby et al recommend that evaluation of an NDPH patient
should include MRI with and without enhancement and MRA (Magnetic Resonance
Angiography). These are done to rule out other conditions such as the
spontaneous cerebrospinal fluid (CSF) leak and cerebral venous sinus thrombosis
discussed earlier. If these tests are negative, Goadsby et al recommend
considering a lumbar puncture (spinal tap) to rule out infection as well as
conditions related to CSF pressure such as
pseudotumor cerebri, which can also mimic NDPH.
What is the treatment
Many doctors consider NDPH to be the most treatment refractory (not responsive
to treatment) of headache disorders. Unfortunately, NDPH can be very disabling
because it often does not respond to preventive or abortive medications. Some
cases have shown successful preventive treatment with Neurontin (gababentin) and
Topamax (topiramate). Otherwise, since no successful treatment regimens have
been devised specifically for NDPH, most specialists work with the same
medications prescribed for chronic Migraine.
New daily persistent headache is now classified as a primary headache disorder.
As you look at the symptoms, you'll find that some of them are characteristic of
tension-type headache; others are more characteristic of Migraine disease. NDPH
is unique, however, in that many patients can tell you the exact date when their
headache began. It is characterized by continuous daily head pain, varying in
intensity, and sometimes accompanied by some Migrainous symptoms. It's important
that NDPH be diagnosed carefully and correctly after ruling out other conditions
that can present the same symptoms. Unfortunately, at this time, there are no
treatments specifically outlined for NDPH.
The International Headache Society. "The
International Classification of Headache Disorders, 2nd Edition." (ICHD-II)
September, 2004. www.i-h-s.org.
Goadsby, Peter J., MD, PhD, DSc, FRACP, FRCP;
Silberstein, Stephen D., MD, FACP; Dodick, David W., MD, FRCPD, FACP. Chronic
Daily Headache for Clinicians. Hamilton, Ontario: BC Decker. 2005.
Li, D & Rozen, TD (2002). "The clinical
characteristics of new daily persistent headache." Cephalalgia 22 (1),
66-69. doi: 10.1046/j.1468-2982.2002.00326.x.