In 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 spontaneous 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
To be diagnosed as NDPH, headache must last more than three months and be daily from within three days of onset. It is bilateral, has a pressing/tightning (non-pulsing) quality, is mild to moderate in intensity, and is not aggravated by routine physical activity. Patients must also experience both of the following:
In 2002, Li and Rozen conducted the largest study of NDPH to date based on 56 patients from the Jefferson Headache Center in Philadelphia:
82% of patients knew 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 patients had a prior personal history of headache.
29$ of patients had a family history of headache.
68% reported nausea.
66% reported photophobia.
61% reported phonophoiba.
55% reported lightheadedness.
Imaging and 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) 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
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). Since it's so difficult to find medications that work and the headache is unremitting, NDPH patients all too often find themselves in the situation of either suffering from medication overuse (rebound) headaches or at the very least, trying desperately to avoid them. Otherwise, since no successful treatment regimens have been devised specifically for NDPH, most specialists work with the same medications prescribed for chronic Migraine.
As you look at the symptoms of NDPH, you'll find 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 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.
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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.