New Daily Persistent Headache

New daily persistent headache is a persistent headache that is daily and unremitting from or within 3 days of onset, which the patient can recall clearly, lasting over 3 months. It has no characteristic features and is a diagnosis of exclusion.

The prevalence is about 0.03 to 0.1% of the population. It begins mostly in adolescents and young adults, with a peak at 10 to 25 years, and it is more common in women.

Subtypes. The migrainous form resembles chronic migraine, and the tension type form resembles chronic tension type headache. Many patients have features of both.

Triggers. Preceding infection (such as Epstein-Barr virus infection or influenza), stressful life event, extracranial surgery, and a flu like illness.

Course. About one third remit within 2 years, and the rest persist and are refractory to many treatments.

Pathophysiology.

The mechanism is unknown. Postinfectious or neuroinflammatory change, cervical spine or craniocervical dysfunction, cytokine activation and central sensitisation have been proposed.

A hypermobility disorder and autonomic dysfunction have been associated.

• Sudden daily headache with a clearly remembered onset, continuous from the first day.
• Bilateral pressing or pulsating pain of mild to severe intensity, with or without photophobia, phonophobia and nausea.
• No relief with usual analgesics; often sleep disturbance, mood change and cognitive complaints.
• Normal neurological examination.

Red flags.

• Orthostatic pattern (spontaneous intracranial hypotension), or worse with Valsalva, lying down or on waking.
• Papilloedema, visual loss, pulsatile tinnitus (idiopathic intracranial hypertension).
• New onset over age 50 with scalp tenderness, jaw claudication or raised ESR (giant cell arteritis).
• Fever, neurological deficit, seizure or recent head and neck trauma.

• Detailed history and neurological and fundus examination; diagnose only after ruling out secondary causes.
• MRI of the brain with contrast and MR venography; MRI of the spine for suspected cerebrospinal fluid leak.
• Lumbar puncture with opening pressure for suspected raised or low pressure.
• ESR and CRP for patients over 50 years; thyroid function, full blood count and infection screen.
• Screening for mood disorders, sleep disorders and medication overuse.

Differential diagnosis. Chronic migraine, chronic tension type headache, spontaneous intracranial hypotension, idiopathic intracranial hypertension, cerebral venous thrombosis, post-traumatic headache, cervicogenic headache, hemicrania continua, medication overuse headache and giant cell arteritis.

• No treatment has proven benefit in randomised studies; use migraine or tension type headache treatments by the clinical subtype and tolerance, and set realistic goals.
• Limit analgesic use to under 10 days each month to avoid medication overuse headache; avoid opioids and caffeine containing analgesics.
• Amitriptyline 10 mg orally at night, increased by 10 mg every 1 to 2 weeks as tolerated to 30 to 50 mg at night. Maximum 75 mg at night. Review at 6 to 8 weeks and stop if there is no benefit. Monitor sedation, anticholinergic effects, postural hypotension and mood; baseline ECG over age 40 or with cardiac risk. Avoid after recent myocardial infarction, with arrhythmia, in angle closure glaucoma or urinary retention, and with serotonergic drugs; cap at 50 mg in older adults; reduce dose in hepatic impairment; avoid in pregnancy unless benefit outweighs risk.
• Topiramate 25 mg orally at night for 1 week, increased by 25 mg weekly in 2 divided doses to 100 mg daily. Maximum 200 mg daily. Review at 3 months and stop if there is no benefit. Monitor bicarbonate, mood, weight, kidney stones and visual symptoms. Halve the dose when creatinine clearance is under 70 mL/min; contraindicated in pregnancy and effective contraception is needed.
• Cognitive behavioural therapy, sleep hygiene, graded exercise, and treatment of anxiety and depression.
• Treat identified contributors: cervical spine dysfunction through physiotherapy, hypermobility, and sleep apnoea.

Monitoring. Review at 4 to 6 weeks and 3 months, then every 6 months; track a headache diary and function.

Referral and escalation. Headache specialist for failure of 2 preventive drugs; urgent review if red flags emerge.

Special groups. Adolescents: school support and psychological treatment. Pregnancy: avoid topiramate and review other drugs.