New daily persistent headache: controversy in the diagnostic criteria

Update in the understanding of new daily persistent headache

Background Accumulating evidence suggests various specific triggers may lead to new daily persistent headache (NDPH)-like presentations, suggesting that new daily persistent headache is a heterogenous syndrome, and challenging the concept that new daily persistent headache is a primary headache disorder.Method We searched the PubMed database up to August 2022 for keywords including persistent daily headache with both primary and secondary etiologies. We summarized the literature and provided a narrative review of the clinical presentation, diagnostic work-ups, possible pathophysiology, treatment response, and clinical outcomes.Results and conclusion New daily persistent headache is a controversial but clinically important topic. New daily persistent headache is likely not a single entity but a syndrome with different etiologies. The issue with past studies of new daily persistent headache is that patients with different etiologies/subtypes were pooled together. Different studies may investigate distinct subsets of patients, which renders the inter-study comparison, both positive and negative results, difficult. The identification (and removal) of a specific trigger might provide the opportunity for clinical improvement in certain patients, even when the disease has lasted for months or years. Nonetheless, if there is a specific trigger, it remains unknown or unidentified for a great proportion of the patients. We need to continue to study this unique headache population to better understand underlying pathogenesis and, most importantly, to establish effective treatment strategies that hopefully resolve the continuous cycle of pain.

Is daily headache related to asthma? Results from a population-based survey

OBJECTIVE

Despite the high worldwide prevalence of asthma and headache, little is known about the association between these conditions. The objective of our study was to evaluate the association between asthma and daily headache in a representative sample of the general population of South Korea.

METHODS

We retrospectively analyzed 7984 individuals included in the Second Korean National Health and Nutrition Examination Survey (KNHANES II), a prospectively administered survey performed in 2001 by a government organization within the Ministry of Health and Welfare. After adjustment of risk factors for daily headache, multivariate logistic regression analysis was performed to evaluate the association between asthma and daily headache.

RESULTS

Of 7984 individuals, 69 (0.9%) had daily headache and 429 (5.4%) had asthma symptoms. Daily headache was significantly more prevalent in subjects with asthma symptoms (14/429, 3.3%) than in those without (55/7555, 0.7%; p < 0.001). Of the 4833 nonsmokers, 46 (1.0%) had daily headache and 287 (5.9%) had asthma symptoms, with daily headache being significantly more prevalent in subjects with asthma symptoms (11/231, 4.8%) than in those without (35/4602, 0.8%; p < 0.001). Multivariate logistic regression showed that the odds ratios for daily headache were 2.3 (95% CI: 1.21-4.33, p = 0.01) in all individuals with asthma symptoms and 3.4 (95% CI: 1.65-7.12, p = 0.001) in nonsmokers with asthma symptoms.

CONCLUSION

Individuals with asthma symptoms are at higher risk of daily headache than those without the symptoms, suggesting a link between these conditions.

[Different headache forms of chapter 4 of the International Headache Classification]

Chapter 4 of the International Classification of Headaches contains a group of clinically very heterogeneous primary headache forms. Little is known about the pathogenesis of these headache types and therapy is usually based on isolated case reports and uncontrolled studies. The forms include primary stabbing headache, primary cough headache, primary exertional headache, primary headache associated with sexual activity, hypnic headache, primary thunderclap headache, hemicrania continua and the new daily persistent headache. Some of these headache forms may be of a symptomatic nature and require careful examination, imaging and further tests. Primary and secondary headache forms must be carefully distinguished.

Commentary: development and validation of the Asian Migraine Criteria (AMC)

Precise and manageable diagnostic criteria are vital for researchers and clinicians dealing with headache. The lack of clear and accessible markers of the biological distinctions between different types of headache means that criteria are determined by expert consensus. The International Classification of Headache Disorders (ICHD) criteria are the current benchmark and are evolving. They are effective for research as they exclude questionable cases from consideration, but in clinical practice they are used inconsistently by neurologists, and rarely by general practitioners, because of complexity. In this issue of the Journal of Clinical Neuroscience, Ghandehari et al. have proposed a new set of criteria, the Asian Migraine Criteria (AMC). These criteria perform well against the gold-standard ICHD, but are almost as complex. They do not have the simplicity of the ID Migraine tool. Nevertheless, they are welcome: any tool that general practitioners may be attracted to use that increases the accuracy of headache diagnosis is to be applauded.

Patients with sudden onset headache not meeting the criteria of the International Headache Society for new daily persistent headache. How to classify them?

We conducted a retrospective analysis of the records of 1348 patients regularly treated at the headache clinic of Department of Neurology of Santa Casa de São Paulo, Brazil. Sixty-two patients reported history of daily and persistent headache. From the 62 patients selected, only 21 (group 1) could be diagnosed with new daily-persistent headache (NDPH) according to the International Headache Society (HIS) 2004 criteria. The 41 remaining patients (group 2) could not be diagnosed with NDPH according to IHS-2004 once they presented two or more migraine attack-related symptoms, such as: nausea, photophobia, phonophobia and vomiting, in different combinations. It was not possible to classify them in groups 1 to 4 of primary headaches either. How to classify them? We suggest that the criteria are revised. And one way we can classify them, would be the subdivision: NDPH with migraine features and without migraine features that would allow the inclusion of all individuals present who has a daily and persistent headache from the beginning