Overview

A persistent headache can be the most crippling feeling. Although nothing seems physically wrong, it can be debilitating to the extent where the individual needs a painkiller, lie down in a dark room, away from noise and screens and just wish the headache away. Many times, there is no effective medication to cure the headache, and it can continue for days at a time. Accompanying nausea can worsen the situation.

What is the new daily persistent headache?

New daily persistent headache (NDPH) is a relatively rare type of chronic headache that begins suddenly and continues daily from that point forward. It is part of a chronic, persistent headache. It has been implied that NDPH is a syndrome rather than a standalone disease.

Its prevalence is about 4% in the general population. Since it is very rare, there are a limited number of studies on the same. Apart from stress, viral and bacterial infections can also be triggers.¹

According to the International Classification of Headache Disorders, NDPH is diagnosed when the headache: 

• Starts abruptly and becomes daily within 24 hours
• Persists for more than three months
• It is not due to any other condition like infection, brain tumour or trauma

NDPH does not have distinct episodic phases like migraine or tension headaches. It tends to be unrelenting and resistant to many standard treatments. 

Clinically, some individuals describe the onset of the headache as “thunderclap”, whereas others say it is insidious with exacerbation in pain at certain times. It is mostly bilateral, with the pain being located towards the top of the head or diffuse.⁶

The biology of stress

When put under stress, our body shows some changes due to the activation of the HPA (hypothalamic-pituitary-adrenal) axis. The HPA axis secretes cortisol and adrenaline when the body is stressed and prepares us for the fight or flight response. Some amount of stress is essential for us to function well, and that is termed eustress. Chronic type of stress, also known as distress, can be harmful to the body due to constant levels of cortisol and adrenaline in the body.

A short episode of stress shows symptoms like:

• Altered digestion
• Increased heart rate
• Faster breathing
• Pupils dilate
• The liver releases glycogen, increasing glucose in the blood
• Tinnitus
• Diarrhoea and nausea

When the stress is removed, the body parameters become normal again. But what about the cases where there is chronic stress? 

Chronic stress affects all the organs of the body, having effects that include:

• Increased inflammation in the body
• Food is not effectively digested
• Sleep disorders
• Pain in muscles and joints
• Altered immune system

The body has a central and peripheral circulatory system. When the body is under stress, the blood circulation is more active in the peripheral areas like limbs and head, ready for the fight or flight response. This is at the expense of the blood circulation required for the central organs of the body, the digestive system. The digestion slows down, assimilation of nutrients from food is reduced, and transport of the nutrients to the organs and other parts of the body is affected. Chronic stress can continuously cause this cycle and make the body vulnerable to a plethora of non-communicable diseases- NDPH being one of them. 

How can stress trigger NDPH?

Major stressors in life have been known to cause NDPH, which include:

• Loss of a loved one
• Job loss
• Financial stress
• Academic pressure
• Bullying
• Post-traumatic stress disorder (PTSD)
• Career stagnation
• Relationship issues
• Divorce 

Impact on the brain

• Brain chemistry imbalance

Stress can alter serotonin levels, which control mood and feelings of well-being. Low serotonin levels are observed in individuals with depression and headache disorders.

• Central sensitisation

Continuous chronic stress over a long period can make the brain more sensitised to pain. Severe, lasting pain can be caused by even the mildest of triggers.

• Neuroinflammation

Stress increases the release of proinflammatory cytokines, which can inflame the nervous system and contribute to pain pathways.

• Autonomic dysfunction

Chronic stress can cause an imbalance in the central control of blood pressure, heart rate, etc, which can lead to altered vascular tone, further contributing to headaches.

The role of mental health in NDPH

Individuals with NDPH have higher rates of anxiety, depression and PTSD. This leads to further sensitivity to pain and worsens the headaches.

Diagnosis

A careful and detailed patient history with relevant family history is critical to diagnosing NDPH. Their daily routine, the challenges they face at their work front or academic front, coping mechanisms, triggers and the timing of the headaches can help understand the underlying cause for the headaches.

There are various mental health screening tools available, like the PHQ-9 for depression and GAD-7 for anxiety. The headaches are very much real and not imaginary, making it a requisite to have a holistic approach to their management.

Management

Having a holistic and multidisciplinary approach is essential in the management of NDPH, as traditional non-steroidal anti-inflammatory drugs (NSAIDs) or antacids or anti-seizure or mind-altering drugs have limited benefit.

Medications

Medicines that can help alleviate symptoms can also be habit-forming. Hence, caution must be observed when trying any drugs. Studies have suggested that NDPH is persistent and highly resistant to treatment by traditional drugs. ⁴

Cognitive behavioural therapy

Cognitive behavioural therapy in the form of guided relaxation, doing activities that one likes and facing situations that have caused anxiety to gradually come out of it can be some of the ways NDPH can be managed.

Mind-body therapies

Guided meditations like the Mind Sound Resonance Technique (MSRT) and Yoga can all help in the gradual relaxation of the mind and body, thereby giving more control over thoughts. The deliberate relaxation of each part of the body during Savasana and Yoga Nidra and the sankalpa has a positive impact on the mind. The changes can be seen at the individual's personality level.

Lifestyle changes

A regular schedule of meals, sleep, and wake times can work wonders for the health of an individual with NDPH. 

Having a balanced diet with proteins, fruits and vegetables can uplift the mood and maintain constant energy levels throughout the day. Regular mealtimes help with blood sugar fluctuations. The inflammation in the body also decreases, and blood pressure normalises, leading to reduced headaches.

Playing a sport or engaging in other physical activities like aerobics, zumba, yoga, etc can help in boosting the circulation, leading to a reduction in headaches.

What the future holds

Transcranial magnetic stimulation has shown promising results in individuals with NDPH by decreasing the severity of the headache, reducing depression and anxiety scores.²

Conclusion

Though NDPH is a rare form of disease, many continue to be plagued by headaches. Timely diagnosis of NDPH can help alleviate symptoms sooner and improve outcomes.