Introduction

New daily persistent headache (NDPH) is a chronic and persistent headache that occurs daily. NDPH often presents in people who have never experienced regular headaches before. This type of headache can cause tension-type headaches and migraines, which typically continue for more than 3 months.¹ This is according to the diagnostic criteria introduced in 1994 and is known as the Silberstein-Lipton criteria. ^2,3 The types of medication used for headaches depend on the severity of pain and the type of headache. Over-the-counter painkillers such as paracetamol are commonly used for NPHD. It is important to use the correct painkillers for the specific type of headache experienced, as this may not always improve the condition of the headache and can cause persistence. 

Understanding NDPH

Clinical features

One of the most common clinical features of NDPH develops abruptly; therefore, people affected by NDPH can give clear information on the details of the headache during a medical history review. The features of the pain are similar to a chronic migraine, which includes vomiting and nausea in severe conditions.³ 

Many symptoms that show with NDPH are blurred vision, lightheadedness, and disruption in sleeping patterns.⁴ The pain level can vary from mild to severe, and the location of the pain is bilateral, which means that it can develop on both sides of the head.³ Pain that throbs or pulses, nausea, light and sound sensitivity, aura, and a more noticeable fluctuation in pain intensity are the hallmarks of a migraine.  Nevertheless, NDPH pain should not be triggered by moderate physical activity or sensitivity to light and sounds. These are some of the symptoms that differentiate NDPH from chronic migraines; however, sensitivity to surrounding light and loud sounds triggers migraines.  

There are common triggers and risk factors associated with NDPH, and these include prior stress, infections, and trauma to the head. Although a family history of headaches is not a clinical feature of NDPH, this can be seen in headaches such as migraines. Previous flu-like illnesses and viruses such as Epstein-Barr virus and herpes simplex virus are some of the risk factors associated with NDPH.⁵ There is also a link between people who are affected with NDPH and the prevalence of psychiatric conditions - a clinical study found that NDPH patients experience anxiety, and  40% of them have symptoms of severe depression, approximately.⁶

Medication overuse and headache chronification

Medication overuse headache (MOH) is caused by the common use of pain relief medication like non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and analgesics.⁷ Examples of NSAIDs are ibuprofen and aspirin, which are easily accessible over-the-counter drugs. The frequent misuse of these medications can temporarily relieve pain but can also worsen headaches. People who are affected by NDPH overuse medication for mild headaches, which in turn increases the intensity of headaches.⁸ The medication intended to treat the headache ends up being the main cause of it. The most common headache type to turn into MOH is migraines.⁹ Nevertheless, in other headache types, a higher frequency of headaches is linked to a greater risk of medication overuse. Also, the type of medication increases the chances of MOH. For example, opioids have a higher risk of causing MOH in comparison to NSAIDs.

Exploring the link between NDPH and medication overuse

NDPH and uncontrolled use of medication are linked because excessive use of painkillers like ibuprofen may trigger or intensify NDPH symptoms. While MOH is a distinct diagnosis characterised by headaches caused by excessive usage of painkillers, NDPH is a new, abrupt, daily, and persistent headache that may or may not be related to medication overuse. If the persistent daily headache is due to medication overuse, a diagnosis of NDPH is not appropriate. 

In a meta-analysis study including 2155 NDPH patients, it is estimated that approximately 31% of adults who participated in the studies have overused medication.¹⁰ Overuse of medication is not always linked to NDPH but is linked to infections and stressful life events.  Approximately 40% of these patients showed a relation to these events, therefore, medication overuse is not the primary cause of NDPH.¹⁰ Although medication overuse can sometimes play a role in NDPH, timely and appropriate treatment can effectively control symptoms.

MOH may mimic NDPH, especially if medication use escalates shortly after headache onset, therefore creating diagnostic challenges. It's important to determine whether frequent medication use is a cause of MOH or a response to it. Nevertheless, withdrawal from overusing medication may indicate whether MOH is the underlying cause of your NDPH. After the withdrawal period, if headache symptoms improve, this suggests that MOH is the primary factor of headaches. However, if headache symptoms do not resolve after withdrawal, this suggests that MOH is not a contributing factor.  

Clinical management and treatment 

The treatment and clinical management of NDPH include relieving the symptoms and improving the quality of life. The type of medication prescribed will depend on whether the pain is a tension or a migraine type. For acute symptoms, over-the-counter drugs are commonly used however, in symptoms similar to migraine, topiramate and amitriptyline are medicines used as they help prevent migraine formation.¹¹ In addition to this, botulinum toxin, also known as Botox, is used to treat chronic headaches such as NDPH and migraines.¹² This treatment option is more suitable for adults who do not want to use medication for a long period of time however, the only disadvantage is that it can be expensive. 

For children, the occipital nerve blocking procedure can be an alternative form of treatment. This involves a steroid injection to the occipital nerve, at the back of the head. A study on children affected by NDPH has shown improvement in headaches after the nerve blocking procedure.¹³ Although this is a proven safe procedure, there could be side effects such as allergic reactions or even nerve damage.

Ways of reducing medication overuse include educating people with NDPH and limiting the medication used in cases of acute symptoms. Multiple treatment methods of both medicated and non-medicated treatment methods can be used, such as cognitive behavioral therapy (CBT) and changing lifestyles. CBT can be a good management option for children and adolescents as it helps with stress, anxiety, and pain management. Another advantage of this therapy is that it reduces the use of medication, reducing the risks of MOH. 

FAQs 

What causes a new daily persistent headache?

There is no known cause for NDPH; however, there are many factors that could be triggers.

Why do I still have a headache all day, even after taking medicine?

This may be a condition called medication overuse headache caused by excessive use.

How to treat chronic headaches daily?

Taking the accurate medication and changing lifestyle, such as dietary changes and exercising daily. 

Can low iron levels cause daily headaches?

Yes, low iron could be associated with headaches, as this causes low oxygen levels in the brain, which then triggers headaches. 

What is the difference between chronic daily headaches and NDPH?

Chronic daily headaches refer to migraines and tension-type headaches, whilst NDPH is a new and sudden headache. 

How to get rid of an NDPH?

NSAIDs, antidepressants, and botulinum toxin are a few of the treatment options available. 

Summary 

In some cases, medication overuse may contribute to NDPH; however, this is not always the case. NDPH is a type of headache that affects individuals across all age groups, including children, adolescents, and adults. Although it shares clinical features with chronic migraine, its phenotypic overlap does not necessarily indicate a shared underlying cause. There is a greater link between underlying infections, diseases, and trauma to the head being the primary source of NDPH. Although there are limited treatment options specifically for NDPH, a balance of treatment is vital. Siting a healthcare professional frequently reduces the risk of overusing these medications and experiencing MOH. For a better understanding of NDPH, research is critical to deepen our understanding of how it develops and to guide the development of more effective, evidence-based treatment strategies.