New Daily Persistent Headache—Not So Rare, Especially in Adolescents



STOWE, VT—The case goes something like this: A 14-year-old girl reports that she has had headaches for a couple of years. The headaches started one day and have been occurring every day since. Her headaches have some migrainous features, but she has been told that she does not have migraine. Imaging reveals nothing out of the ordinary. Many OTC and prescription drugs have failed. When the other causes and types of chronic daily headache are ruled out, what is left is new daily persistent headache, which is common in children starting around the early teen years, but has been poorly described in the literature.

Most of what is known about new daily persistent headache comes from adult data, said Herbert G. Markley, MD, but a clearer picture of this headache disorder in children and adolescents is beginning to emerge. Dr. Markley, Director of the New England Regional Headache Center in Worcester, Massachusetts, made his comments at the Headache Cooperative of New England’s 19th Annual Headache Symposium.

New Daily Persistent Headache
In 1986, Walter Vanast described new daily persistent headache as a “benign” syndrome that resolved regardless of treatment in 73% to 86% of patients in three to 24 months. “That was then, and this is now,” said Dr. Markley. “We think it is the opposite of benign, possibly the most refractory of all headache syndromes.” There have been many attempts at diagnostic criteria for new daily persistent headache over the years, but according to Dr. Markley, the closest to being correct was Steve Silberstein’s 1994 description—more than 15 days per month, more than four hours per day, frequently constant without medication but may fluctuate, and no history of tension-type headache or migraine that increases in frequency and decreases in severity in association with the onset of this new headache. “Nothing building up, in other words,” explained Dr. Markley. It involves sudden onset of a constant unremitting headache that is constant in location and does not meet the criteria for hemicrania continua or attributed to another disorder, as ruled out by negative lab studies.

“In our sample of patients—adolescents and adults—we’ve been able to identify several different patterns,” Dr. Markley said. “Some have been described in previous publications, and some have not.” The self-limiting type resolves without therapy in most patients. The refractory type is resistant to outpatient and inpatient aggressive treatment. Then there’s the transformed type, in which patients have episodic migraine or episodic tension-type headache maybe a couple of times a month but then suddenly awake one day with a really bad headache that lasts 24/7. Often patients can remember the exact day that it happened.

“I now routinely ask in every intake interview with a patient who has daily headache, ‘Was there a time when your headache suddenly changed from a couple of times a month or once or twice a week to 24/7?’” commented Dr. Markley. “If the answer is ‘yes,’ then you’re dealing with new daily persistent headache.” A fourth type, which has not yet been reported, is one in which patients with chronic migraine suddenly, abruptly again, wake up with the same headache but it’s 24/7 all of a sudden. It did not build up. “This is harder to diagnose,” Dr. Markley said, “but it may be very common.”

The severity of new daily persistent headache also varies. “We see three different severity patterns,” said Dr. Markley. In the mild form the daily headache is much like chronic tension-type headache. More common is the moderate pattern. “We call it a sawtooth pattern,” Dr. Markley said. “The good days are like tension-type headache, and the bad days are like severe migraine.” And then there’s the severe type, with disabling continuous high-level pain 24/7.

Not So Uncommon
Approximately 4% of adults have chronic daily headache. Of these, how many have new daily persistent headache? The estimates vary from 0.1% to about 11%. But the estimates of new daily persistent headache in children and adolescents are much higher—from about 20% to 36% of patients with chronic daily headache. “Many more teenagers and kids have new daily persistent headache than adults,” Dr. Markley said. Migrainous symptoms and migrainous triggers are common in this population of headache patients.

More than 40% of patients with new daily persistent headache have some sort of febrile illness close to the onset of this kind of headache. In one study more than 50% had positive Epstein-Barr serology, 23% occurred after a minor head injury, 10% had pseudotumor, or idiopathic intracranial hypertension, and 10% started after noncranial surgery.


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