New daily persistent headache

New daily persistent headache

Since 2004, New Daily Persistent Headache (NDPH) has been recognized as a distinct primary headache syndrome. It is classified as a Primary Headache Disorder by the ICHD-2 classification system (by the IHS) using number 4.8. 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 New Daily Persistent Headache can be confirmed. Two conditions in particular that must be ruled out are spontaneous cerebrospinal fluid leak and cerebral venous sinus thrombosis.



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 leak (aka 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 Idiopathic intracranial hypertension, which can also mimic NDPH.

For a proper diagnosis, the headache must last more than three months and be daily from within three days of the onset. It is bilateral, is mild to moderate in intensity, and is not aggravated by routine physical activity. Patients do not typically experience sensitivity to light, sound or smells.

For some patients, an infection or flu-like illness occurred directly prior to the onset of the headache.

Over 80% of patients can pinpoint the exact date of the onset of their headache.


1. 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.

2. History and physical and neurological examinations do not suggest any of the disorders listed above, 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.


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 (gabapentin) and Topamax (topiramate). Doxycycline has also proven effective in a small study. [1] Otherwise, since few successful treatment regimens have been devised specifically for new daily persistent headache, most specialists work with the same medications prescribed for chronic migraine.


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