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
headache?
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:
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photophobia, phonophobia or mild nausea and
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neither moderate or severe nausea nor vomiting
In 2002, Li and Rozen conducted the largest study of NDPH to date based on 56 patients from the Jefferson Headache Center in Philadelphia:
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82% of patients knew the exact day their headache started.
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In 30% of the patients, the onset of the headache occurred in correlation with an infection or flu-like illness.
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38% of patients had a prior personal history of headache.
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29$ of patients had a family history of headache.
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Accompanying symptoms:
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68% reported nausea.
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66% reported photophobia.
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61% reported phonophoiba.
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55% reported lightheadedness.
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Imaging and laboratory testing was unremarkable except for an unusually high number of patients who tested positive for a past Epstein-Barr virus infection.
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How is NDPH
diagnosed?
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
for NDPH?
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.
Summary:
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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References:
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.
