Current Pain and Headache Reports

, Volume 15, Issue 1, pp 47–50

New Daily Persistent Headache: Controversy in the Diagnostic Criteria

Article

DOI: 10.1007/s11916-010-0160-4

Cite this article as:
Young, W.B. Curr Pain Headache Rep (2011) 15: 47. doi:10.1007/s11916-010-0160-4

Abstract

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.

Keywords

New daily persistent headache Chronic daily headache Chronic migraine Chronic tension-type headache Hemicrania continua Silberstein-Lipton criteria Methylprednisolone Doxycycline 

Introduction

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 [1] in 1986, it was widely diagnosed when it became part of the Silberstein-Lipton criteria for chronic daily headache in 1994 [2]. 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.

Discussion

In one recent population-based epidemiological study, NDPH occurred in 0.1% of patients [3]. Other estimates are that NDPH makes up 1.7% to 10.8% of chronic daily headache [4]. Vanast [1] 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) [4]. 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 [5]. 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 [7]. 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.

The criteria for NDPH according to the 2004 International Classification of Headache Disorders, Second Edition (ICDH-II) [8] are provided in Table 1.
Table 1

ICHD-II criteria for new daily persistent headache

Description:

 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.

Diagnostic criteria:

 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

(Data from the Headache Classification Committee of the International Headache Society [8])

ICHD-II International Classification of Headache Disorders, Second Edition

Anecdotally, the exclusion of patients with too many migrainous features from the ICHD-II was contentious from the onset and has remained a source of consternation for many headache experts. This controversy is based on two separate issues. First, varying descriptions of the rate of migrainous features, largely between American and non-American case series, may have given different experts a different feel for the clinical features of NDPH. Second, the IHS’ need to define “attacks and not syndromes” may have compelled the subcommittee to define the clinical features rather than describing the disorder on the basis of the onset of the symptoms. Thus, the classification committee came up with a definition of attack features that excluded an abundance of migrainous features. This allowed the designation based upon rapidity of onset only if the phenotype was like tension-type headache, not if it was like migraine headache. How could the IHS policy of describing attacks be bypassed if a daily headache has features of tension-type headache but not if it has features of migraine? This peculiar, sudden onset of a daily headache raises the same issue of what turned the headache on irrespective of the headache features. These switch-related questions are equally valid regardless of how many migrainous features the patient has. In either case, the rapid onset of daily headache evokes the same distinct differential diagnosis and whose application may, at times, be urgent (Table 2).
Table 2

Differential diagnosis of new daily headaches

New daily persistent headache

New daily persistent headache mimics

Chronic migraine

Primary headache with medication rebound

Chronic tension-type headache

Posttraumatic headache

Combined features of migraine and tension-type headache

Subarachnoid hemorrhage

Benign thunderclap headache

Low cerebrospinal fluid pressure syndrome

 

Pseudotumor cerebri

Cervical or intracranial artery dissections

Cerebral venous thrombosis

Reversible cerebral vasoconstriction syndrome

Neoplasm

Chronic meningitis

Postmeningitis headache

Sphenoid sinusitis

Temporal arteritis

Hypertension

Chronic subdural hematoma

(Adapted from Evans [19])

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 [8]. 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. [13] suggested that cervical spine hypermobility may predispose to the development of NDPH. Others have suggested cervical venous abnormalities may underlie NDPH [14]. 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 [17] and Swidan [18] 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.

Conclusions

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.

Disclosures

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.

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Thomas Jefferson University, Jefferson Headache CenterPhiladelphiaUSA

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