Overview

Headaches are a common brain condition that often feels like a dull or sharp throbbing pain in the head. Headaches can affect people of all ages and can impact our quality of life, productivity at work or school and our emotional wellbeing. There are over 150 types of headaches, which can vary in how severe they are and how long they last, from mild tension-type headaches to strong ones like migraines and cluster headaches. Headaches tend to come and go at predictable times due to factors such as dehydration, stress, or injury; however, some types can be a sign of something more serious.¹

New daily persistent headache (NDPH), an uncommon and chronic headache disease, is one such severe kind of headache. NDPH is characterised by symptoms such as sudden onset and constant, daily pain that often lasts for at least 3 months. It is a difficult condition to treat since these kinds of headaches can happen unpredictably and do not respond to usual headache treatments.²

This article will look at how NDPH differs in symptoms from other headache disorders. It is important to understand how we can distinguish NDPH from other types of headaches in order to get the appropriate diagnosis and treatment management, since this disorder does not respond to usual treatment methods.

What is New Daily Persistent Headache (NDPH)?

There are two main categories that headaches fall under: primary and secondary. Primary headaches are triggered suddenly by lifestyle aspects that cause dysfunction and over-activity of the pain-sensitive structures, such as blood vessels and nerves in your head, rather than from a medical condition. Secondary headaches are caused by an underlying medical condition or issue.¹

New daily persistent headache (NDPH) is a chronic type of headache disorder that falls under the category of primary headaches. NDPH is an uncommon condition, affecting approximately 30 to 100 individuals per 100,000 people. NDPH can affect people of all ages for a variety of reasons, but is more likely to occur in children and teenagers and is also more common in adult women.²

Causes of NDPH

We don’t know exactly what causes NDPH to start, though there are some suspected risk factors that include lifestyle or medical events that seem to trigger the disorder. There are two forms of NDPH: primary and secondary.^{2, 3, 4}

• Primary NDPH – the cause is unknown
• Secondary NDPH – caused by a condition such as an infectious viral illness or bacterial infection (this is more common in children) or a medical condition such as dysregulation of the central nervous system (CNS), cranial surgery (of the head) or a stressful life event that affects you psychologically (more common in adults)

These viral and bacterial infections can include:^2,4

• Salmonella
• E. coli
• COVID-19
• Dengue fever
• Meningitis
• Epstein-Barr virus (mono)
• Herpes simplex virus (HSV)
• Cytomegalovirus (CMV)

NDPH may also arise as a result of other medical conditions that impact the brain and central nervous system, including:^2,4

• Subarachnoid haemorrhage or chronic subdural hematoma - a bleed between your brain and skull, often after a head injury
• Post-injury headaches, such as from a traumatic brain injury (TBI) or a concussion
• Inadequate CSF as a result of a CSF leak in your skull or close by
• High cerebrospinal fluid pressureIntracranial neoplasms (brain tumour)
• Cerebral venous sinus thrombosis (CVST) – a rare blood clot in your brain
• Idiopathic intracranial hypertension (IIH) – a buildup of pressure in your skull
• Infections of the nervous system, such as chronic meningitis
• Overuse of medications, in particular, those that treat headaches, which can cause rebound headaches

Other risk factors include:⁴

• Those who have a pre-existing history of anxiety or depression
• Individuals who have had migraines or tension-type headaches in the past
• Those with cervical spine joint hypermobility (excessive flexibility of the neck, causing pain)

Symptoms of NDPH

NDPH affects your brain directly and shares similar symptoms with more common types of headaches, such as tension-type headaches and migraines. However, these symptoms differentiate it from these types of headaches in several different ways. Your headache disorder needs to meet different requirements to be classed as NDPH as per the International Headache Society’s ICHD-3 - International Classification of Headache Disorders.

Key diagnostic criteria include:^2,3,4

• New – the headaches began suddenly without any recent history of similar episodes
• Persistent – continuous, unrelenting head pain that does not subside over time
• Daily - the headaches are long-lasting, all day, every day, for at least three months straight
• Headache – the pain is moderate to severe, ranging from a throbbing to a dull aching pain^,, disrupts daily life and impacts quality of life and emotional well-being 
• A headache appears suddenly, abruptly and you can recall exactly when it began, where you were, and what you were doing

These symptoms differ from those seen in more common headache disorders, where they seem to come and go and resolve within hours or days rather than in months or years, and are not continuous. They also develop gradually rather than starting suddenly and can be relieved by medication, whereas NDPH cannot.

NDPH shares characteristics with both tension-type headaches and migraines, and it must include at least two features associated with each type in order to meet diagnostic criteria.⁴

Tension headache symptoms include:⁴

• Pain on both sides of your head (bilateral)
• Pressure or tightening in/around the head
• Pain does not get worse depending on what you are doing, such as routine physical activity

Migraine symptoms include:⁴

• Pain only on one side of your head
• Throbbing, pounding or pulsing pain
• Sensitivity to light (photophobia)
• Sensitivity to sounds (phonophobia)
• Allodynia – pain due to a stimulus that does not usually cause pain, such as a light touch
• Mild nausea and vomiting
• Vertigo
• Visual auras

Diagnosis of NDPH

Diagnosis is often delayed and takes longer due to its overlapping symptoms with other, more common types of headache disorders and a lack of awareness. Patients often have to undergo multiple tests before receiving a correct diagnosis.⁴ 

When you visit your GP or doctor, they will ask you about any family history of headache disorders as well as your symptoms, how long the headache has been going on for and when it started. Based on these symptoms, they will rule out other causes of the headache and narrow down the type.⁴ 

There is not a single test that can directly diagnose NDPH, but you may have to take tests that can help to rule out these other headaches and causes, such as a brain tumour or infection, and get you closer to a diagnosis of NDPH. These tests include:^3,4

• CT scan
• MRI scan
• Blood test (to look for infection)
• Lumbar puncture (spinal tap) – removal of cerebrospinal fluid from your spine

Since NDPH can only be diagnosed as NDPH after it has persisted for more than three months, your headache can often be diagnosed as a chronic tension headache, chronic migraine, or rebound headache from overuse of headache medication. If you seek medical care before the 3-month mark, it is why it often gets misdiagnosed. You may, however, be diagnosed with “probable NDPH” and will be formally diagnosed with NDPH once over the 3-month mark, and your symptoms are still the same.⁴

Treatment and Prognosis of NDPH

There is no exact cure for NDPH, making it a difficult condition to treat even once diagnosed. It is important to get diagnosed as soon as possible in order to avoid unnecessary treatment, which could lead to further misdiagnosis and a delay in receiving proper treatment. 

The main medications used to treat and manage NDPH are:^2,4

• Migraine prevention medications such as triptans and beta-blockers like propranolol
• Antidepressants  such as nortriptyline and amitriptyline are used to treat pain disorders
• Antiseizure medications such as topiramate, gabapentin and clonazepam
• Medication that treats irregular heartbeats, such as mexiletine
• Botulinum toxin A injections (Botox)  that block nerve and pain signals
• Experimental anaesthetics/antidepressants  such as ketamine

There are other therapies and treatment methods that don’t involve medications that can help manage NDPH, such as:^3,5

• Cognitive behavioural therapy (CBT), including relaxation therapy
• Healthy lifestyle modifications and choices such as good quality and regular sleep, stress management, good diet, hydration and exercise
• Physical therapy, acupuncture, and  massage for neck and muscle strain and pain

The prognosis for NDPH can vary from person to person. Once you start taking the appropriate preventative treatment after diagnosis, it can take six to eight weeks and even up to two years before it takes effect and you have relief from your symptoms.^2,4 Although it improves for some in most adults, NDPH will persist on and off (relapsing-remitting). NDPH is more likely to respond to treatment when treated earlier and often requires multiple types of treatment methods to be effective, including medication and other physical therapies and lifestyle modifications for more long-term management.

Summary

New daily persistent headache (NDPH) is a rare headache disorder characterised by symptoms such as sudden onset, which you can recall when it happens exactly; lasting all day, every day; and persisting for more than three months. This is different from other headaches, such as tension or migraine headaches, which begin more gradually and stop after a few hours or days. They also get better with treatment, and NDPH does not. The symptoms of these headache disorders are often also present in NDPH, making it hard to diagnose and therefore treat. NDPH often will be a lifelong condition that comes and goes for most adults. A variety of treatment methods used together, including both drugs and physical/psychological therapy, are needed for more effective relief. Further research is needed to understand the causes and improve treatment options for NDPH.