New Daily Persistent Headache - What's Known About It?
New daily persistent headache (NDPH) is a primary headache disorder, which means that it's not caused by another condition. Many patients with NDPH experience symptoms common to Migraine, but NDPH is not a form of Migraine.
What Is NDPH?
NDPH is unique in its characteristics:
- It's a daily headache that develops very quickly, over fewer than three days.
- Many patients can identify the exact date the headache began.
- The patient usually has no prior history of headache disorders.
- It can go on for years, literally, regardless of the best of treatment.
- It can also stop as abruptly as it started.
NDPH can be one of the most disabling headache disorders, at least in part due to it's being refractory (nonresponsive) to treatment.
Although they fall into the one diagnosis of new daily persistent headache, clinical observations indicate two main subtypes of NDPH:
- Self-Limited: usually stops within several months to several years without any treatment.
- Refractory: Resistant to all treatment, even the most aggressive outpatient and inpatient treatments. Can occur for years to decades with no relief.
Here's the diagnostic and classification information for NDPH from the International Headache Society's International Classification of Headache Disorders, 2nd edition (ICHD-II):1
4.8 New daily-persistent headache (NDPH)
Headache that is daily and unremitting from very soon after onset (within 3 days at most). The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity. There may be photophobia, phonophobia or mild nausea.
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:
- 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.
Rozen looked at studies to talk about possible triggering events for NDPH. He groups triggering events and / or predisposing factors into two groups:
- "Central nervous system inflammation with probable enhanced CSF (cerebrospinal fluid) cytokine production." He specifically mentions elevation of cerebrospinal fluid (CSF) tumor necrosis factor alpha (TNF alpha) levels. TNF alpha is a pro-inflammatory immunoregulatory protein that is involved in immune and inflammatory activities in the brain and pain initiation. Rozen and colleagues have found these levels to be elevated in many NDPH patients. This group would include post-infection, post-toxic exposure, and stressful life event triggers.
- Cervicogenic with underlying cervical hypermobility syndrome. Rozen and his colleagues have a observed a similar body build and constitution in NDPH patients. They observed patients being tall, thin, and having a long neck, characteristics often seen in patients with hereditary connective tissue disorders. This group would include post-surgical triggers and possibly stressful life event triggers, which he describes as "crying, laying in bed or curled up on the could lead to neck irritation."
NDPH as been recognized as a separate and distinct headache disorder for a relatively short period of time when compared to Migraine and other headache disorders. At this time, there are no specific treatments recommended that are based on clinical evidence. Most Migraine and headache specialists use the same medications in attempting to treat NDPH as they use for treating chronic Migraine.
A small minority of patients have had success with the use of gabapentin (Neurontin) or topiramate (Topamax). Rozen has shown some success in treating NDPH with daily doses of doxycycline, a TNF alpha inhibitor. This makes sense when we look at the first triggering group.
Other treatments that have had some limited success are mexiletine, IV corticosteriods such as methylprednisolone, and nerve blocks.
Wrapping It Up:
As discouraging as NDPH can be, it's important to remember that it hasn't been recognized as a distinct headache disorder until fairly recently. The knowledge of NDPH is now where the knowledge of Migraine once was, so hope should not be lost that it will be better understood and more treatable soon. More research is in order to more fully investigate all aspects of NDPH so that better treatment options can be made available.
Anyone who has been diagnosed with NDPH and is make no progress with treatment and anyone who thinks they may have NDPH would be well served by seeking treatment with a qualified Migraine and headache specialist.
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