Overview 

Headaches can present in numerous forms, affecting individuals of all ages, with varying manifestations, durations, and causes. The new daily persistent headache, or NDPH, is one such rare type of headache. Chronic or acute forms of NDPH are possible. Chronic migraine is one of the only chronic conditions where the patient experiences daily acute pain. Those with significant frequent headaches can identify the age their headaches began. NDPH is commonly a secondary headache disorder, but is otherwise considered to be idiopathic. Though not life-threatening, it is significantly impactful to quality of life, and over-the-counter medication frequently proves ineffective. As there is no cure, many neurologists focus on understanding the nature of the patient's pain and establishing practical management goals. It is distinct from the patient’s usual headache pattern, and is abrupt in onset or reaches peak intensity within the first hour of its onset; attack duration is always a minimum of three months. Acute NDPH lasts less than three months and can be treated, whereas chronic NDPH lasts more than three months, requires more problematic treatment, and is more obstructive to quality of life.^1,2,3

Acute vs chronic NDPH duration and onset: A more comprehensive assessment

Acute New Daily Persistent Headache (NDPH) begin suddenly, lasts less than three months and has not resolved. It is clinically complex and may interfere with daily life. NDPH is sudden and well-defined, allowing patients to identify the day their headache began. It doesn’t change or get any better. The diagnosis is more complicated as the symptoms often resemble tension-type headache or migraine. While the correlation is not well established, viral infections or stressful conditions are sometimes associated with NDPH and can act unexpectedly.⁴

Chronic new daily persistent headache, an uncommon phenomenon, starts suddenly and persists for more than three months with no resolution. It is almost always not curable and has a dramatic effect on daily living. Among the more distinct features is that the onset can be abrupt, and the individual will remember the exact day it started. The constancy of pain and its independence from relief or variation make it nearly impossible to address or categorise. Diagnosis might be even more complex if the presentation is similar to that of tension-type headache or migraine. Although the precise aetiology of NDPH remains undetermined, certain patients have been reported to have identifiable trigger factors, including viral infections, stressful life events, or even minor head trauma.⁵

Possible causes and associated triggers

In a systematic review, almost 50% of patients with NDPH could identify an occurrence that initiated their headaches. Viral or flu-like illness was the most common precipitant, reported in 22% of cases. Surgery or anaesthesia and severe stress were among other important precipitants, at approximately 9% each. Fever or head trauma are often reported as causes in children. Established triggers for NDPH are viral infections, surgery, and severe stress, although hormonal changes and medications can also serve as triggers. Surprisingly, almost half of NDPH cases have no obvious cause, underlining the mysterious nature of NDPH. In addition, overmedication, especially with analgesics, can itself result in chronic headaches. Psychological stress is, of course, one more important variable that plays an important role in the majority of headache disorders.⁶

Diagnosis

The diagnosis of New Daily Persistent Headache (NDPH) is a diagnosis of exclusion, and the patient has a clear recall of the exact day when the headache began. According to ICHD-3 (International Classification of Headache Disorders) NDPH is a daily persistent headache of sudden onset that persists for greater than three months; cases of shorter duration are classified as “acute NDPH.” There is also usually no history suggestive of chronic headache or a gradual decline. Imaging of the brain, often via MRI with MR venography, is necessary to rule out tumours, bleeding, vascular clots or cerebrospinal fluid abnormalities to make the diagnosis. The physical examination is typically unremarkable, and the required MRI scans will reveal some neurological abnormalities. Key diagnostic criteria are daily onset of headache, recollection of the specific date of onset, a lack of prior increasing frequency, and persistence for greater than 3 months. While NDPH may mimic migraine, diagnosis typically relies on the history of onset, although alternative diagnoses should be considered if the onset is unclear.^7,8

Treatment

There is no one successful cure, but treatments include:

1. Medications: Anti-inflammatories, migraine medications, CGRP, and antidepressants
2. Infusion therapies: corticosteroids or DHE infusions for short-term relief
3. Neuromodulation devices: Cefaly or gamma Core for electrical stimulation
4. Dietary, stress, and hydration management lifestyle changes
5. Other treatments: Acupuncture, biofeedback, physical therapy⁹

FAQs

How common is NDPH?

It is a rare form of headache. Incidence has been reported to be between 30 and 100 per 100,000. The headache is more common among girls and even more so among children and adolescents.

Does NDPH resolve on its own?

While in some cases NDPH resolves spontaneously over time, particularly in young patients, in others it can persist for years. Most NDPH is very resistant, and most patients struggle to find a therapy that works effectively.

Can NDPH be prevented?

Prevention is difficult as the cause is not known. Nevertheless, some known precipitating factors should be avoided, including infections, head trauma, and very high stress.

Is NDPH related to mental health?

Of course, NDPH can lead to depression, anxiety, and a reduced quality of life. The lack of efficacious treatments is a source of frustration for patients.

Summary

• New Daily Persistent Headache (NDPH) is a rare headache disorder with sudden onset and daily persistence. Chronic NDPH lasts for more than 3 months, and acute NDPH is less than 3 months in duration
• Patients can report the exact date of onset of the NDPH and characterise the pain intensity as moderate to severe
• Viral illness, surgery/anaesthesia, major stress, hormones, and withdrawal from medications are all commonly reported triggers of NDPH
• The history of sudden onset, along with negative brain imaging studies that rule out alternative diagnoses, allows the confirmation of the diagnosis of NDPH
• Treatment can include medications to prevent the disease, surgeries or interventions, behavioural modification, complementary and alternative medicine (CAM) therapies, or other practices – but complete cures are more the exception than the norm. NDPH can be debilitating to quality of life and mental well-being, and may necessitate multidisciplinary interventions