Introduction: Finding relief beyond conventional medicine

Headaches can not only be a symptom or side effect of something else, but also a condition of its own. Most people are familiar with the pain; however, to have headaches over the long term that aren’t relieved by medication can be distressing and difficult to manage emotionally, physically and mentally. New Daily Persistent Headache (NDPH) can occur without a trigger and warning. As the name suggests, it is persistent, i.e, it can last for years.¹

NDPH presents in 2 ways: 

1. Primary NDPH: Experts do not know why it is happening
2. Secondary NDPH: Is linked to another health condition, such as a viral infection 

The headaches that a patient may experience could have symptoms suggestive of tension-headaches, migraines, or a mix of both.¹

The unforgiving persistence of the headaches can provide a tough challenge for people, often interrupting activities in their daily routine. Chores that would have been previously completed quickly and easily or without assistance may suddenly require more motivation and energy to complete. 

Unfortunately, NDPH can be resistant to conventional treatment options, which is why people are exploring alternative avenues to identify whether there is solace away from medication found in a traditional pharmacy. 

This article will present some non-pharmacological options that may support the management of NDPH.

What is New Daily Persistent Headache (NDPH)?

NDPH affects just 0.03% of the population, being more common in females, occurring at any age, including children, but with the majority of people being in their 20’s-30’s. A defining characteristic is that the person remembers when it started, where they were and what they were doing. It can occur suddenly, but it is only diagnosed after other possible causes have been ruled out. In essence, having a prolonged headache isn’t immediately diagnosed as NDPH; it requires investigation, treatment failure and the dismissal of other more serious conditions that may present with persistent headache. NDPH does not necessarily occur in people who have had frequent or debilitating headaches before, and is often defined by the lack of relief within 3 days from the start, continuing for a minimum of 3 months. More research is needed into NDPH to understand the condition, why it occurs and why it is resistant to treatment.

Even at high doses of medication and a combination of different medications, a high percentage of patients with NDPH do not get better. People with NDPH can be categorised into 3 groups: 

1. Persistence of symptoms, usually felt daily over years; often linked to younger patients, and the patient also having depression or anxiety
2. Treatment temporarily helps but eventually stops helping, usually within the first 2 years
3. Pausing - restarting of symptoms where there are headache-free moments, lasting weeks or months, before the pain starts again 

Another challenge of persistent headaches would be balancing the medication used for treatment. Not only would it be important to ensure that doses aren’t being exceeded, but it is also crucial to remember that overuse of medication, even at prescribed doses, can ironically also cause headaches. This can be countered by having days without taking the medication, alternating between different medicines, and using the lowest strengths where possible.²

The limitations of conventional medication, whether its failure to help prevent and treat the headache, its restricted use, or side effects, leave room for alternative treatment options to help provide relief.

Supplements that may support NDPH management

Magnesium (Mg)

Deficiencies in magnesium can be the cause of headaches, so taking a magnesium supplement can address that deficiency, thereby preventing and treating any more headaches.³

Benefits of taking Mg include: 

• Well-tolerated
• Safe
• Inexpensive
• Can prevent and treat 
• Works against different types of headaches, including migraines and tension headaches 

Different researchers have agreed that taking Mg can help with headaches. Two different trials confirmed that people who took a daily dose of 600 mg of trimagnesium dicitrate or 600 mg magnesium citrate orally showed a reduction in the migraine frequency by almost 42%.

Side effects of taking Mg supplements include diarrhoea or stomach pain, however taking another salt (version) of it may help. Furthermore, taking too much Mg can cause toxicity within the body, leading to complications involving the heart muscle and lungs, with patients with kidney disease being more likely to be affected.³

Riboflavin (Vitamin B2)

Benefits of taking Vitamin B2 include: 

• Well-tolerated
• Safe 
• Treat and prevent migraines in children
• Lack of toxicity
• Inexpensive
• Few serious side effects

In a review of studies, all seven conducted on adults found that taking 400 mg of Vitamin B2 daily had a positive effect on those experiencing headaches. Additionally, five out of seven studies showed that Vitamin B2 supplements were effective for children suffering from headaches.⁶

A study involving 6 - 18 year olds who suffer from migraines found that the average intensity of their headaches decreased, along with its duration, leading to their support, including in patients with NDPH.⁵ Another benefit for the children was fewer days missed from school.

There is a lack of clinical evidence to promote the use of Vitamin B2 in guidelines, but so far due to its efficacy and safety, the conclusions are encouraging. 

Coenzyme Q10 (CoQ10)

A compound similar to vitamins found in the body, CoQ10 has a role in helping the body work efficiently.⁹

Benefits:

• Well-tolerated
• Efficacious over time
• Also have positive effects on quality of life⁹

Several studies suggested that CoQ10 can decrease not only the number of headaches experienced but also how long they occur. There is debate however, on whether they can reduce the severity, as 1 study found it did, at a daily dose of 100 mg, however, others found that severity remained unaffected.^7,8

Herbal remedies with potential benefits

Butterbur

• Effective at preventing migraines in multiple studies with a daily dose of 50 - 150mg^10,11
• Can be used for preventing headaches in both adults and children, but not if pregnant, breast-feeding or taking certain medications
• Recommended by the American Headache Society and Canadian Headache Society at preventing migraines but not the UK and Germany, due to safety concerns 
• Generally well tolerated, the most common side effect is burping
• Only buy brands that have removed any alkaloids or plant components that can cause cancer
• May be linked to toxic effects on the liver, but more research is needed to confirm this. Nonetheless, monitoring of liver function is important¹⁰

Feverfew

• A plant related to the daisy family
• Small reduction in migraine frequency
• No effect on severity or duration of migraine attacks

Ginger

• Known to have positive effects on nausea and digestion
• Research hasn’t assessed its use as the main treatment, but more so as an aid alongside other medication, where it can help reduce the frequency and intensity of headaches
  

Other Potential Herbs that have been mentioned as possibly helping reduce the burden of NDPH: peppermint, willow bark and curcumin, but more research is needed to focus on them

Relaxation techniques and mind-body approaches

Relaxation techniques can help to calm the body, manage pain and provide an alternative route to control headaches without the need of taking anything orally. The following listed can make a positive difference for people suffering with NDPH:

Biofeedback

• Training your body to control and change body reactions such as temperature, heart rate or muscle tension, thereby reducing the effects of the migraine¹²
  

Mindfulness meditation

• Becoming aware of your different senses, emotions and thoughts in the present moment. Can help reduce stress, which in turn reduces the episodes of headaches¹³

Yoga and gentle movement

• Reducing tension in muscles and improving circulation may help to improve headache frequency, duration and pain intensity in the short-term¹⁴

Progressive Muscle Relaxation (PMR)

• Involves tensing and then relaxing different muscle groups; it has proven to be clinically effective at preventing migraines¹⁵

Eye movement exercises and breathing exercises

• Moving eyes in certain directions to strengthen the eye muscles, and doing deep-breathing exercises has been proven to reduce the frequency, intensity and duration of headaches¹⁶
  

Considerations before starting alternative therapies

Make sure you consult a healthcare provider before taking any supplements that have not been prescribed. Herbal items can interact with conventional medication, potentially making them less effective or even making your condition worse. On the other hand, alternative therapies may be able to be taken in conjunction with conventional prescribed medication, rather than instead of it, being seen as more of a helper to reach beneficial results, rather than a replacement.

They can also have side effects, which should not be confused with worsening of your condition. Furthermore, even herbal remedies have optimal doses, and it would be important to find out the correct dose that would lead to a beneficial therapeutic effect, as taking too little may not work, and too much may lead to undesirable effects. 

Remember to start only one new therapy at a time, to determine whether or not any new effects or improvement can be attributed to it. Moreover, any supplements or herbal products should be genuine, of high quality and standardised, to minimise the chance of side effects from them.

For people who are not getting relief from pain from prescribed medication, trying alternative therapy can seem like a ray of hope, but remember to have realistic expectations, that while these options help some people, they may not help everyone. It is, however, worth noting that consistency and patience are key factors in determining whether or not these routes work for you. They may need to be taken for months before the maximum benefit is felt; it is about giving them a chance, rather than quickly dismissing them.

Summary

There is ongoing research into NDPH to determine the mechanisms of why people suffer with it and what can be done to help. As guidelines do not give a clear direction on how best to treat NDPH, it is currently suggested that it should be treated based on the symptoms of the type of headache it presents, i.e, treat as a migraine or tension-type headache. People may find hope and relief with alternative therapy, which is an evolving area for researchers.