New Daily Persistent Headache (NDPH)

What is new daily persistent headache?

New daily persistent headache (NDPH) is a rare chronic headache disorder. The symptoms of the NDPH start very suddenly and are moderate to severe. It’s not a dangerous condition, but the symptoms last for months and can greatly disrupt your life and routine activities. Most cases of this condition are also difficult to treat.

NDPH has two main forms, primary and secondary.

• Primary NDPH: Healthcare providers and experts often call this “idiopathic” NDPH, meaning experts can’t determine why it’s happening.
• Secondary NDPH: This is when NDPH happens in connection with or because of another condition or disease, most commonly a viral illness.

Who does new daily persistent headache affect?

NDPH can affect anyone but is more common in women and people assigned female at birth. It also may happen more often in children and teenagers, especially between ages 10 and 18, but it’s still possible at any age.

How common is new daily persistent headache?

There’s limited research on how common NDPH is, but the available data indicates that it’s rare. The best available studies, which are from Norway and Spain, indicate that it happens in 30 to 100 out of every 100,000 people.

How does new daily persistent headache affect my body?

NDPH typically only affects your brain directly. However, when it has migraine-like features, it may cause light sensitivity, sound sensitivity, vertigo, nausea or vomiting.

What are the symptoms of new daily persistent headache?

NDPH symptoms aren’t unique, but some happen in an unusual way.

• They’re long lasting. A requirement for diagnosing NDPH is that you have the headache for at least three months.
• The pain is constant. Most experts define NDPH as having nonstop pain once it starts.
• You remember when it started. The International Headache Society’s official guidelines, the International Classification of Headache Disorders, requires that you remember when the headache started. That means a healthcare provider will only diagnose NDPH if you can remember exactly when the headache started, including where you were and what you were doing.
• The pain is usually moderate to severe. People with NDPH usually have moderate pain or worse. Because the pain is also constant, this has the potential to severely disrupt a person’s life and activities.

Headaches that happen with NDPH can look like standard tension headaches, migraines or have features of both. Tension headache symptoms can include:

• Pain on both sides of your head.
• Pain feels like pressure or tightening in or around your head.
• The pain doesn’t get worse depending on what you’re doing.

Migraine features can include:

• Pain on one side of your head.
• Pain that feels like throbbing, pulsing or pounding.
• Photophobia (sensitivity or pain from light).
• Phonophobia (sensitivity or pain from sounds).
• Nausea and vomiting.
• Vertigo.
• Visual auras.

What causes new daily persistent headache?

Experts don't know exactly why NDPH happens, but they suspect certain events and circumstances are possible triggers. Going through stressful events is a common feature for people who develop NDPH. People are also likely to develop NDPH after certain medical events, but there’s not enough data to confirm if these events either cause or contribute to NDPH.

One such key type of trigger is having an infection. People often develop NDPH while they have a viral or bacterial infection, including:

• Epstein-Barr virus (a key cause of mononucleosis, or just “mono”).
• Salmonella.
• E. coli.
• Dengue fever.
• COVID-19.
• Meningitis or encephalitis.

You can also have NDPH as a secondary effect of another medical condition that directly affects your brain or central nervous system. Some examples of this include:

• Subarachnoid hemorrhage (bleeding into the subarachnoid space between your brain and an outer membrane; this often begins very suddenly with a “thunderclap headache”).
• Low cerebrospinal fluid (CSF) pressure, usually from a CSF leak in your skull or around your spinal cord.
• High CSF pressure that causes a headache.
• Post-injury headache (such as from a concussion or traumatic brain injury).
• Medication overuse (especially for medications that treat headaches or migraines), which can cause “rebound headaches.”

Is new daily persistent headache contagious?

No, NDPH doesn’t spread from one person to another. While NDPH can happen after some infections, having those infections isn’t a guarantee of developing NDPH.

How is new daily persistent headache diagnosed?

Diagnosing NDPH is a multistep process.

• The first step is to gather information about your symptoms, including how long you’ve had the headache, when it started and what you’re feeling from it.
• The second step is to rule out other causes of the headache.

The first step usually involves a healthcare provider talking to you and asking you questions. They may also do a neurological exam to check for signs of any related problems with your nervous system.

After the first step is complete, the healthcare provider needs to make sure there isn’t another cause for NDPH. That’s key because NDPH shares so many symptoms with other neurological conditions.

Diagnosing before reaching the three-month requirement

It’s common for people to seek medical care before they reach the three-month requirement for having NDPH. In these cases, your provider will go through all the same diagnostic steps but won’t finalize the diagnosis. In these instances, your provider will diagnose you with “probable NDPH.” Once you reach three months with symptoms, they can formally diagnose you with NDPH.

What tests will be done to diagnose new daily persistent headache?

There aren’t any tests that can directly diagnose NDPH. Instead, tests focus on ruling out other conditions that could cause similar symptoms, especially conditions that are dangerous or life-threatening. Some possible tests include:

• Computerized tomography (CT) scan.
• Magnetic resonance imaging (MRI) scan.
• Lumbar puncture (spinal tap).
• Blood testing to look for signs of infection.

Depending on your medical history or the symptoms you describe, your provider may also recommend other tests. You can talk to your provider to learn more about the tests they recommend and the reason for the recommendation. They’re the best source of information relevant to your situation and can tailor the information to your specific circumstances.

How is new daily persistent headache treated, and is there a cure?

NDPH is often a difficult condition to treat. Some cases of this condition are easier to treat, especially those with migraine-like symptoms. Tension headache cases are more likely to resist treatment. Time is also a factor, as NDPH is more likely to respond to treatment when treated earlier rather than years after symptoms begin.

Medications are usually the main way to treat NDPH. However, finding a medication that can treat this condition is often difficult. Some examples of possible medication types include:

• Antidepressants. Medications like amitriptyline, nortriptyline and venlafaxine, which also treat pain disorders, can sometimes help NDPH.
• Antiseizure medications. Some examples include gabapentin or topiramate.
• Botulinum toxin injections (commonly known by the brand name Botox®). This drug blocks nerve signals, including pain signals. Other types of nerve blocks can also help.
• Medications used to prevent migraines. Examples include beta-blockers like propranolol and angiotensin-II receptor blockers like candesartan.
• Experimental anesthetic/antidepressants. Ketamine, a powerful anesthetic that also sees experimental use in treating resistant depression, can sometimes help NDPH.

Complications or side effects of the treatments

The possible complications and side effects that can happen with the treatments depend on many factors, especially the specific medication. Your healthcare provider can tell you more about the side effects and complications that are most likely for you, and what you can do to prevent them or minimize their effects.

How do I take care of myself or manage the symptoms?

Treating NDPH yourself is difficult, especially when you don’t have a diagnosis. That’s because this condition often won’t respond to standard headache treatments. That means over-the-counter medications, and even many prescription medications, aren’t effective at stopping NDPH.

You also shouldn’t try to self-diagnose or self-treat NDPH because a moderate or severe headache that starts suddenly is also a key symptom of a stroke. Strokes happen because of blood clots or other blockages in your brain, cutting off blood flow. The longer you wait to get medical care after symptoms start, the less likely that the symptoms are reversible. Eventually, a stroke causes permanent brain damage or even death.

If you or someone you’re with has this symptom, especially with other stroke symptoms, you should immediately call 911 (or your local emergency services number).

IMPORTANT: To recognize the symptoms of a stroke, remember to think FAST:

• F is for face. Ask the person to smile. Look for a droop on one or both sides of their face, which is a sign of paralysis (facial hemiplegia) or muscle weakness.
• A is for arm: A person having a stroke often has muscle weakness or paralysis on one side. Ask them to raise their arms. If they have new one-sided weakness or paralysis, one arm will stay higher while the other will sag and drop downward, or won’t raise up at all.
• S is for speech. Strokes often cause a person to lose their ability to speak. They might slur their speech or have trouble choosing the right words.
• T is for time. Time is critical, so don’t wait to get help! If possible, look at your watch or a clock and remember when symptoms start. Telling a healthcare provider about when the symptoms started can help the provider know what treatment options are best for you.

How soon after treatment will I feel better?

Unfortunately, there’s no way to know whether or not different treatments will work. It’s common for many medications to have no effect on NDPH. In general, it takes about six to eight weeks for a preventive treatment plan to take effect. Your healthcare provider is the best person to talk to you about how fast a medication — if effective — should work. They can tell you what you can and should expect, and what you should do if treatment isn’t effective.

How can I reduce my risk of developing new daily persistent headache, and is it preventable?

Unfortunately, NDPH happens unpredictably. That means there’s no way to prevent it. Many of the possible triggers also happen unpredictably, so there’s also no way to effectively reduce your risk.

What can I expect if I have new daily persistent headache?

If you have NDPH, you should expect a headache with moderate to severe pain. This headache lasts for at least three months, and the pain occurs every day and doesn’t stop. Some people do get relief from treatment, but many don’t.

How long new daily persistent headache lasts

For some people, NDPH is something they’ll experience for years before it eventually goes away. The headache usually stops within three years for people who fall into this category. In others, the headache never goes away. When people have NDPH that doesn’t respond to treatment and doesn’t stop on its own, this condition can be so disruptive that it interferes with their ability to work, participate in social activities and more. Learning to live with this condition also can involve providers from multiple specialties, such as a mental health provider to treat the psychological effects of living with chronic pain.

Outlook for new daily persistent headache

On its own, NDPH isn’t a dangerous condition. However, living with moderate or severe chronic pain is known to affect a person’s mental and emotional well-being negatively. People with chronic pain conditions commonly also develop or have mental health conditions like anxiety and depression.

Multiple factors make this condition difficult to diagnose. These include:

• This condition is rare.
• There aren’t any diagnostic tests that can definitively confirm it.
• Imaging tests usually don’t show any changes that could explain the symptoms.

Because of all the above factors, people with NDPH may need to see multiple healthcare providers before they get a diagnosis. As this is a condition that providers can only truly diagnose after a person has symptoms for at least three months (though they can diagnose it as a probable case before that), people with NDPH often live with the symptoms without a definite answer on what’s causing their condition. That can further contribute to mental health concerns like anxiety and depression.

How do I take care of myself?

If you have NDPH, a healthcare provider can offer suggestions on what you can do to try to help this condition. For the most part, there’s not much that most people can do to manage this condition. However, there’s some evidence that focusing on your general health and well-being can improve the odds that certain treatments — especially medications — will work. In general, the health behaviors that seem most beneficial include:

• Eat a healthy diet.
• Get regular physical activity.
• Have a regular sleep schedule and get enough sleep.

When should I see a healthcare provider?

In general, you should see a healthcare provider if you don’t have a history of headaches and develop a new, moderately painful headache that meets any of the following criteria:

• It doesn’t get better with over-the-counter medications and/or it gets continually worse.
• It happens on only one side of your head or involves throbbing, pounding or pulsing pain.
• You have other symptoms like severe nausea and vomiting, or sensitivity to light and sound.

The above criteria aren’t just signs of NDPH, but can also happen with several other severe headache disorders or health conditions. These usually happen with serious conditions that a healthcare provider should examine to see if you have a concern that needs medical care.

When should I go to ER?

Severe headaches that happen suddenly, don’t get better or worsen over time are also potential signs of severe or dangerous conditions. There are also other symptoms that indicate you need to get medical care immediately. These include:

• Weakness, numbness or tingling on one or both sides of your body.
• Loss of vision or disruptions in your vision, like blurred vision, double vision, etc.
• Confusion or feeling very tired.
• Trouble with balance or speaking.

Is new daily persistent headache different from migraines, cluster headaches or other headache disorders?

Yes, NDPH is different from other headache disorders. NDPH can share some features with migraines and other headache disorders, but is different enough that experts classify it on its own.

Does new daily persistent headache ever go away?

NDPH goes away for some people, but not for all. However, there’s no way to predict when this will happen or to whom.

When should I be concerned about recurring headaches?

You should be concerned about recurring headaches that are moderately painful or worse, or that don’t get better with treatment or go away on their own. If you have headaches every day, it’s a good idea to talk to a primary care provider. While it’s common to have daily headaches for mostly harmless reasons, like needing eyeglasses or contacts, you can also have them for other, more serious reasons.

Is it normal to have a slight headache every day?

No, it’s not normal to have a headache every day. If you have daily headaches, it’s a good idea to talk to a healthcare provider. They can determine if you have a serious condition that’s causing your headaches or if you need to see a specialist for further care. In many cases, a provider can rule out serious conditions and help you find ways to stop headaches from happening or treat them when they do.

A note from Cleveland Clinic

New daily persistent headache (NDPH) is a rare condition where a person develops a new headache that’s moderately painful or worse and doesn’t get better over time. This condition is difficult to treat, and many people with it have pain and other symptoms for years. Sometimes, the headache goes away on its own, but this happens unpredictably. Healthcare providers can suggest treatment options, but more research is necessary before experts can say why this condition happens and what means are most effective in treating it.