New Daily Persistent Headache: Controversy in the Diagnostic Criteria
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- Young, W.B. Curr Pain Headache Rep (2011) 15: 47. doi:10.1007/s11916-010-0160-4
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New daily–persistent headache is a relatively uncommon type of chronic daily headache. The critical features of the original description and the subsequent Silberstein-Lipton description was the onset: daily headache starts abruptly without a background of frequent or worsening headache. In 2004, the International Headache Society classification committee excluded an abundance of migrainous features. The exclusion of patients with too many migrainous features from the International Headache Society classification was contentious from the onset and is a source of consternation for many headache experts. Many contend that the sudden onset of a daily headache raises the same issue of what turned on the headache, irrespective of the headache features. Switch-related questions about predisposing factors or precipitating events are equally valid regardless of how many migrainous features the patient has. The differential diagnosis, treatment response, or prognoses do not vary by the number of migrainous features. The current International Headache Society definition excludes more than half of patients with new onset of daily headache. This exclusion due to migrainous features could have adverse scientific, diagnostic, and treatment consequences.
KeywordsNew daily persistent headache Chronic daily headache Chronic migraine Chronic tension-type headache Hemicrania continua Silberstein-Lipton criteria Methylprednisolone Doxycycline
A relatively uncommon type of chronic daily headache is new daily persistent headache (NDPH). It is one of four types of chronic daily headache, which also include chronic migraine, chronic tension-type headache, and hemicrania continua. While NDPH is not as common as chronic migraine or chronic tension-type headache, it is a small part of the general neurologist’s practice and it is common in the headache specialist’s office.
First described by Vanast  in 1986, it was widely diagnosed when it became part of the Silberstein-Lipton criteria for chronic daily headache in 1994 . The critical feature of the original description and the subsequent Silberstein-Lipton description was the onset: daily headache starts abruptly without a background of frequent or worsening headache.
In one recent population-based epidemiological study, NDPH occurred in 0.1% of patients . Other estimates are that NDPH makes up 1.7% to 10.8% of chronic daily headache . Vanast  found nausea in more than half of patients, but photophobia and phonophobia only in about 40%. In one clinic-based study, NDPH was more common in adolescents, and was diagnosed in 21.1% of adolescents (13 to 17 years) and 10.8% of adults (18 years and older) . A retrospective chart review using the Vanast and Silberstein-Lipton criteria that was carried out at the Jefferson Headache Center before May 2000 identified 56 patients with NDPH. Of these patients, 82% were able to pinpoint the exact day their headache started; 30% of patients reported onset occurring in relation to an infection or flu-like illness; and 38% reported a prior history of migraine. In many ways, NDPH was similar to migraine: 71% of patients were female, 68% had nausea, 66% had photophobia, and 61% had phonophobia. Other studies have shown clinical features more similar to chronic tension-type headache . Kung et al. [6•] used a Silberstein-Lipton–like definition of NDPH and found the number of migraine days nearly identical for children with NDPH as for chronic migraine of gradual onset. In a clinic-based study, about half of adolescents diagnosed with NDPH according to the Silberstein-Lipton criteria fulfilled too many criteria to be diagnosed as NDPH by the International Headache Society (IHS) criteria . It is not known whether NDPH is best characterized as the rapid onset of a primary headache disorder such as chronic migraine or chronic tension-type headache, or whether it is a more pathophysiologically distinct entity.
ICHD-II criteria for new daily persistent headache
Headache that is daily and unremitting from very soon after onset (within 3 days at most). The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity. There may be photophobia, phonophobia or mild nausea.
A. Headache that, within 3 days of onset, fulfills criteria B–D
B. Headache is present daily, and is unremitting, for > 3 months
C. At least two of the following pain characteristics:
1. Bilateral location
2. Pressing/tightening (non-pulsating) quality
3. Mild or moderate intensity
4. Not aggravated by routine physical activity such as walking or climbing stairs
D. Both of the following:
1. No more than one of photophobia, phonophobia, or mild nausea
2. Neither moderate or severe nausea nor vomiting
E. Not attributed to another disorder
Differential diagnosis of new daily headaches
New daily persistent headache
New daily persistent headache mimics
Primary headache with medication rebound
Chronic tension-type headache
Combined features of migraine and tension-type headache
Benign thunderclap headache
Low cerebrospinal fluid pressure syndrome
Cervical or intracranial artery dissections
Cerebral venous thrombosis
Reversible cerebral vasoconstriction syndrome
Chronic subdural hematoma
This diagnostic quandary has been problematic for the headache community. Several recent papers have essentially bypassed the ICHD-II criteria, basically using the Silberstein-Lipton criteria [6•, 7, 9, 10, 11••]. In a recent article, Robbins et al. [12••], using nonexclusionary criteria, showed that the cohort of patients with NDPH is more than twice the size of the NDPH group that meets IHS criteria. The differences between patients who met IHS criteria with tension-like headaches and those with more migrainous features amounted to this: patients with NDPH with migraine features were more likely to be women and have a history of anxiety or depression while patients with NDPH with tension-like features were more likely to recall the exact day of onset. The groups were similar in pain level, autonomic symptoms, symptoms of allodynia, medication overuse, and response to triptans and nerve blocks. The similarities of treatment response profiles fail to either demonstrate a treatment value for the ICHD’s classification or hint at any biologically valid difference between the two groups.
Robbins et al. [12••] studied the prognosis of the two subgroups: the prognoses of the group with migraine features and the ICHD-II group were similar. Both groups were equally likely to be unremitting, and had similar chances of evolving into episodic headache, defined as fewer than 5 days per month, or being relapsing-remitting. Differences in prognosis did not show a basis for maintaining the ICHD-II’s current exclusion of migraine features.
Robbins et al. [12••] suggested dividing NDPH into “more migraine-like” and “more tension-like” subgroups . This seems like a political concession. They did not present any evidence that the current IHS definitions give a biologically meaningful cut-point within NDPH. As headache specialists, we hope that a new definition for NDPH will not impose arbitrary divisions within it that may hinder scientifically valid investigation. As it stands, for more than half of patients with new onset of daily headache, the ICHD-II’s classification distracts the clinician from the most critical issues: how did the switch get turned on and why doesn’t it get turned off?
If one agrees not to focus on associated symptoms and to diagnose NDPH based on the onset of headache, then attention returns to what the predisposing factors to developing NDPH are, and the nature of the insult, or switch, that initiates NDPH. Rozen et al.  suggested that cervical spine hypermobility may predispose to the development of NDPH. Others have suggested cervical venous abnormalities may underlie NDPH . Furthermore, the observation that children are more likely to acquire NDPH may have biological significance. Viral infection, surgery, and stress may be other biological factors related to the “switch” [15, 16].
Settling on a more rational definition of NDPH also may allow us to bring semispecific treatments to patients with NDPH. In a small case series of postinfectious NDPH patients (or patients who would develop NDPH if the headache had persisted for a few more weeks), intravenous methylprednisolone was given to patients for 5 days, followed by oral steroids for 2 to 3 weeks, and had resolution of their daily headache [11••]. Based upon the observation that cerebrospinal fluid tumor necrosis factor–α (TNFα) levels are elevated in persons with refractory NDPH (as well as refractory chronic migraine), Rozen  and Swidan  have suggested doxycycline, a TNFα inhibitor, may be effective for NDPH. In a small case series of four patients, all had a 50% or greater improvement of headache. If confirmed, these treatment observations should be applied to the benefit of all patients with sudden- or rapid-onset daily headache, not denied to more than half the group that may benefit.
The current ICHD-II criteria of NDPH require the onset of a daily headache in 3 or fewer days and controversially exclude patients with too many migrainous features. This exclusion due to migrainous features could have adverse scientific, diagnostic, and treatment consequences.
Dr. William Young has served on the speaker’s bureau for Allergan, GlaxoSmithKline, Iroko Pharmaceuticals, Merck and Co., Zogenix, Inc., and Astellas Pharma; has served as a consultant for Allergan; has served on the advisory board for Iroko Pharmaceuticals and Merck and Co.; and has received research support from AGA Medical, Advanced Bionics, Advanced Neuromodulation Systems, Inc., Allergan, Capnia, Inc., Chorus, Eli Lilly and Company, Endo Pharmaceuticals, GlaxoSmithKline, MAP Pharmaceuticals, Medtronic, Minster Pharmaceuticals, the National Institute of Neurological Disorders and Stroke/National Institutes of Health.