New daily persistent headache (NDPH): symptoms, diagnosis and management

Great Ormond Street Hospital (GOSH), an NHS children's hospital, describes new daily persistent headache as a type of persistent headache that starts suddenly and happens daily with migraine-like or tension-like features. It was previously called de novo chronic headache, meaning a chronic headache with sudden onset out of the blue. NDPH is unique, GOSH says, in that the headache occurs every day after it starts and very soon becomes unremitting, often in people without a previous history of headaches.

A review of patient experiences published in a medical journal describes NDPH as an idiopathic headache syndrome characterised by the abrupt onset of an unremitting, daily, continuous headache without a history of an escalating headache pattern and not attributable to any other primary or secondary headache disorder. Two clinical subtypes are described: a self-limited form which resolves spontaneously without treatment and a refractory, persistent form in which headaches continue for years.

GOSH says NDPH can begin in childhood, with age of onset ranging from six years to adulthood and an average of 35 years, and is more common in females. It adds that, like other primary headaches, it may be linked to anxiety or panic disorders.

GOSH says the headache is often described as a pressure-like or tightening sensation, often on both sides of the head but sometimes one side or localised to one area. It can fluctuate in intensity, is normally mild or moderate and does not interfere with daily activities, lasts more than four hours a day and persists for more than three consecutive months.

People frequently also have sleep disturbance, pain at other sites, dizziness, worsening anxiety and mood and absence from school or work. Other symptoms include non-specific abdominal pain, back pain, neck pain and diffuse muscle and joint pain. It can resemble chronic migraine, with days of light or sound sensitivity, nausea, throbbing or one-sided pain, or a milder tension-type headache without those features.

A new headache is not automatically NDPH, and the NHS lists features that need urgent assessment. It says to call 999 or go to A&E if you or a child has a headache and has had a seizure, has numbness or weakness in the body or face, it started suddenly and is extremely painful, there has been a head injury within the last 3 months, there is difficulty speaking, balancing, walking or remembering things, drowsiness or confusion, loss of vision, a rash that does not fade when a glass is rolled over it, or a very high temperature, stiff neck or bright lights bothering you.

It says to ask for an urgent GP appointment or get help from NHS 111 if a headache comes with vision or eye problems, is triggered or made worse by coughing, sneezing, bending down or exercising, comes with being sick, or comes with jaw pain when eating or a sore or tender scalp, and for a child with a headache that is getting worse or wakes them at night. It also says to see a GP if you have tried treating a headache yourself and it is not getting better or you regularly get headaches.

NDPH is a diagnosis of exclusion. GOSH says other important conditions such as bleeding or brain tumours can mimic NDPH and present with a new-onset persisting headache, so these must be excluded before a primary headache disorder is diagnosed, and that investigations such as an MRI of the brain and lumbar puncture may need to be performed.

The history is central: the exact onset, the pattern since, associated features and what has been tried. The qualitative study describes many patients visiting several doctors before getting a clear answer, which means diagnosis is often delayed. A headache diary, as the NHS suggests for any headache, can help a clinician see the pattern.

GOSH says NDPH is treated like the headache it resembles and that there is no specific treatment. It lists medicines that have been shown to be effective in studies of adults and children, including amitriptyline, gabapentin, pregabalin, propranolol and topiramate, noting that there are no controlled trials of preventative treatment. In those with migraine-like features it may be worth using migraine preventive treatment.

It says clinicians tend to avoid opioids because of side effects and the possibility of causing medication overuse headache. Treating mental health symptoms alongside the headache may lead to good outcomes. Experimental approaches include occipital nerve blocks and tetracycline medicines. It describes the cornerstones of therapy as lifestyle modification, education, preventative medication, avoiding daily painkillers and attention to routine. The journal review says most therapies are generally ineffective or only partially effective and that there is lack of evidence for any pharmacological, surgical or non-pharmacological treatment.

GOSH says most adults with NDPH will have persistent headaches, although about 15% will remit and about 8% will have a type that comes and goes. It says the outcome in children is not well studied, that some children will have NDPH unresponsive to standard therapies, and that because it is often difficult to treat it often requires a multi-faceted approach.

The experience of living with a daily headache can be wearing. The qualitative study reports patients trying many medicines and non-drug approaches, with variable benefit, and values a good relationship with the clinician and continuity of care. Ask for referral to a neurologist or headache service if headaches persist despite primary care treatment.

On the NHS, a persistent daily headache is first assessed by a GP, with referral to a neurologist or headache clinic if it does not settle or the diagnosis is uncertain. Imaging and lumbar puncture are arranged if there are concerns about other causes. Private neurology consultations and MRI can shorten the wait for assessment, but the main treatments are the same, so a private route is mostly about speed and continuity, and your GP should be kept informed of any medicines started.