Headache is one of the most common complaints in society and often occurs due to temporary reasons. However, there are some headaches that can change life in an instant. New Daily Persistent Headache (NDPH) is exactly such a condition.

In NDPH, the headache appears with a sudden and clear onset day; the patient can specify “my pain started on this exact day.” From the moment it begins, this pain continues every day, without interruption, appearing unexpectedly and quickly becoming chronic. Therefore, it is a type of headache that is difficult to recognize and manage for both patients and physicians.

NDPH can seriously affect a person’s daily life, work performance, and mental state. For this reason, early diagnosis and correct treatment approaches are of great importance.

What is New Daily Persistent Headache (NDPH)?

New Daily Persistent Headache (NDPH) is a rare primary headache disorder included in the International Classification of Headache Disorders. Its most distinctive feature is that the onset day is remembered very clearly. The patient can often easily state:

“My head started hurting on this exact day… and it never went away.”

The headache often begins suddenly and turns into a continuous form within the first 24 hours. From that day on, it continues every day for at least three months. Its occurrence in a person with no previous history of continuous headache makes this condition even more notable.

While migraines or tension-type headaches may become chronic over time with increasing frequency, NDPH starts in an instantly chronic state. In this respect, it can be difficult to recognize and manage.

This persistent and continuous pain can significantly affect a person’s work life, social relationships, and mental health. Therefore, early diagnosis and proper treatment planning are of great importance.

What Causes New Daily Persistent Headache (NDPH)?

The exact cause of NDPH is not yet fully known. This situation makes the disease both mysterious and difficult to manage. However, in some people, certain triggering events can be identified immediately before the onset of headache:

• Viral infections
  This is the most frequently reported triggering factor. NDPH can develop especially after upper respiratory tract infections. Cases associated with Epstein-Barr virus (kissing disease) are among the best-known examples. NDPH cases developing after COVID-19 have also been described.
• Severe stress or traumatic life events
  Situations such as intense psychological stress, anxiety periods, grief, and trauma can prepare the ground for onset.
• Surgical interventions
  Even surgeries performed on other parts of the body can initiate the process by triggering infection or stress response.
• Medical procedures
  Although rare, it can occur after lumbar puncture (spinal fluid removal).

In approximately half of the cases, no trigger can be found. In these individuals, disruption in the central nervous system’s pain processing pathways or genetic predisposition are considered among possible causes.

What Are the Symptoms of New Daily Persistent Headache (NDPH)?

The most distinctive feature of NDPH is headache that continues every day without interruption. Patients often describe it as:

“I’m never completely pain-free on any day, not even for a moment.”

Although symptoms vary from person to person, they may present with the following characteristics:

• Continuity
  The pain is continuous and uninterrupted. Even if its intensity changes during the day, it never completely disappears.
• Pain character
  It can resemble two different profiles:
  — Tension-type like: Pressure-type pain that squeezes the head, usually bilateral
  — Migraine-like: Throbbing pain that may be unilateral, accompanied by light and sound sensitivity, nausea and vomiting
• Pain location
  It can be in the forehead, temples, both sides of the head, or the neck region. In some people, it is limited to one side.
• Intensity
  It is usually at a moderate to severe level and can seriously affect daily life.
• Accompanying other complaints
  Fatigue, difficulty concentrating, sleep problems, dizziness, anxiety, and depressive mood can frequently accompany it.

Who Gets New Daily Persistent Headache (NDPH)?

NDPH is a rare headache disorder that can be seen at any age and in both genders. However, some trends are notable:

• Age
  It mostly begins during adolescence and young adulthood (approximately between ages 10-30).
  However, it can also occur in childhood and advanced ages.
• Gender
  Although it is reported slightly more frequently in women, there is no pronounced female predominance as in migraine.
  It can be seen at similar rates in men as well.
• Previous headache history
  Many NDPH patients have no previous history of regular headache complaints.
  This condition is consistent with the sudden and unexpected onset of the disease.

International Classification of Headache Disorders (ICHD-3) Diagnostic Criteria – 4.10 New Daily Persistent Headache

It is a continuous headache that has a sudden onset, becomes present every day within 24 hours from the beginning, and continues for at least 3 months.

1. The patient reports a headache history that begins on a day/location that can be suddenly and clearly remembered — from that day on, the headache becomes uninterrupted and continuous.
2. The headache becomes daily and continuous from onset or immediately after onset (within 24 hours).
3. The pain continues every day for a period of > 3 months and is uninterrupted.
4. The pain cannot be better explained by another headache disorder (e.g., chronic migraine, chronic tension-type headache) or another cause (secondary headache).

New Daily Persistent Headache (NDPH) – How Is It Diagnosed?

The diagnosis of New Daily Persistent Headache (NDPH) is an evaluation process made by excluding all secondary causes that could lead to similar complaints. This process generally includes the following steps:

1. Detailed patient history: The physician meticulously questions on which day the headache started, whether the pain has subsided at all since that day, the character of the pain, and accompanying symptoms. Being able to provide a clear onset date strengthens the suspicion of NDPH.
2. Physical and neurological examination: On average, neurological examination findings are normal in NDPH patients.
3. Imaging methods: Since suddenly onset and persistently non-resolving headaches bring to mind serious causes such as brain tumors, vascular abnormalities, and infections, imaging of the brain and its vessels is commonly recommended (e.g., contrast MRI, MR venography).
4. Blood tests and other laboratory examinations: Appropriate for ruling out possible secondary causes such as infection or inflammation.
5. Lumbar puncture (spinal fluid collection): Evaluated especially if increased/decreased intracranial pressure or cerebrospinal fluid abnormalities are suspected.

New Daily Persistent Headache (NDPH) Treatment

NDPH is one of the most challenging conditions in the headache world. Its resistance to standard headache treatments and the absence of a single “rescue” therapy makes this situation even more complex. Therefore, the goal of treatment is not to completely eliminate pain, but rather to reduce the intensity and frequency of pain, enabling the patient to regain functionality and quality of life.

Pharmacological Treatments

Frequently used medications in treatment include:

• Prophylactic (preventive) medications:
  • Tricyclic antidepressants (e.g., amitriptyline, nortriptyline)
  • Antiepileptic drugs (e.g., gabapentin, topiramate)
  • Beta-blockers
  • Muscle relaxants
    These medications may not have as high a success rate in NDPH as in other chronic headache types; therefore close monitoring and dose adjustment is required
• Anti-inflammatory/antibiotic approaches:
  If there is a history of infection at the onset of pain, some physicians may try agents such as antibiotics (e.g., doxycycline or minocycline) targeting the “inflammatory mechanism.”
• Injection applications:
  • Nerve blocks: Local anesthetic (e.g., lidocaine) or steroid injections can be applied especially to occipital nerves in the neck region (e.g., Greater Occipital Nerve).
  • Botulinum toxin (Botox): This method, used in chronic migraine treatment, can also provide temporary relief in some NDPH cases.
    These approaches should be considered as an alternative option especially in patients who do not respond adequately to medication or who have limitations in medication use.

Non-Pharmacological Treatments

Rather than focusing only on medications in treatment, adopting a comprehensive and multifaceted approach is quite important:

• Physical therapy and manual therapy: If there is tension or postural disorder in the neck-shoulder region, exercise programs and manual therapy methods guided by a physiotherapist can be beneficial.
• Cognitive Behavioral Therapy (CBT): Individual or group sessions guided by a psychologist or psychiatrist are recommended to cope with anxiety, depression, and functional loss that chronic pain may cause.
• Biofeedback and relaxation techniques: Biofeedback, progressive muscle relaxation, meditation, and breathing exercises can be effective in managing factors such as muscle tension, stress, and sleep disorders.
• Acupuncture and other complementary methods: For some patients, alternative treatment approaches (e.g., acupuncture) may provide relief; although research is limited, it can be considered as additional support.

Multidisciplinary and Long-term Approach

NDPH treatment should not be limited to a single physician or only one method. A team approach where specialists such as neurologists, pain management physicians, physiotherapists, and psychologists work together is the ideal approach. Additionally, the treatment process should be conducted patiently; rather than expecting early results, “controlled recovery” should be targeted.

During the treatment process, the patient’s lifestyle changes (sleep pattern, stress management, avoiding triggering factors) are also very important in terms of follow-up.

NDPH can create a serious burden with its sudden onset and continuous nature; however, with proper planning and a team approach, managing the pain and restoring quality of life is possible.

Frequently Asked Questions About New Daily Persistent Headache (NDPH)

1) What is the fundamental difference between NDPH and chronic migraine? My head hurts every day, does this mean I have NDPH?

Chronic migraine is generally a headache disorder that gradually becomes chronic over time; the frequency of attacks increases and the patient notices their pain-free days decreasing. However, New Daily Persistent Headache (NDPH) shows a completely different onset. The patient remembers the day and even the hour when the pain started quite clearly. The headache becomes uninterrupted with the first day and continues for more than three months without ever disappearing. Therefore, the sudden and persistent onset of the headache is the most important clue for diagnosis. Although experiencing pain every day may suggest NDPH, making a diagnosis definitely requires evaluation by a neurology specialist.

2) Could this headache be a symptom of a dangerous disease (such as a brain tumor)?

NDPH is classified as a primary headache disorder and is not a dangerous disease in itself. However, since suddenly onset continuous headache can also be a symptom of serious conditions such as brain tumors, vascular abnormalities, infections, or intracranial pressure disorders, these conditions must be ruled out before diagnosis. For this purpose, brain MRI imaging, MR venography, blood tests, and if necessary, spinal fluid collection are performed. If no problem is detected in these examinations, it is understood that the headache is not related to an underlying dangerous cause.

3) Does NDPH last a lifetime, can it resolve on its own?

The course of the disease varies considerably from person to person. In some people, the headache may completely disappear on its own within months or a few years without any treatment. However, in a larger group, the headache can last for years and turn into a chronic condition. Unfortunately, it is not possible to know in advance which course will develop in which patient. However, it is thought that NDPH cases that receive treatment early, begin after infection, or have migraine-like features have a better chance of recovery.

4) Why don’t standard painkillers and migraine medications work?

Simple painkillers or triptans often do not show the expected effect in NDPH. This is due to the different underlying mechanism of the disease. In NDPH, a process that increases pain sensitivity in the central nervous system is thought to emerge. That is, the problem is not just vascular dilation or muscle tension; a permanent sensitivity has formed in the pain transmission pathways in the brain. Therefore, treatments such as antidepressants, antiepileptics, and nerve blocks that aim to reduce neuronal sensitivity take precedence in treatment.

5) What should I do if I think I have NDPH?

If your pain appeared with a clear onset day and has continued uninterrupted since that day, you should consult a Neurology specialist without delay. Having a physician specialized in headaches evaluate you will speed up the diagnosis process. Going to the appointment having noted the exact date your pain started, possible triggers such as previous infections or stress, and the daily course of pain will make the physician’s job easier.

6) Is NDPH psychological? Do anxiety and stress cause this disease?

NDPH is definitely not a psychological disease; its origin is neurological. However, prolonged pain can naturally lead to anxiety, restlessness, and depressive mood. Psychological support and treatment are important aids in controlling headaches, but should not be seen as the cause of the disease.

7) Does exercising worsen this pain? Is sports prohibited?

In some people, exertion can increase headache. Therefore, sports are not completely prohibited, but an appropriate program is arranged for the patient under the guidance of a physiotherapist. Correction of postural disorders and strengthening of neck muscles often provide benefit.

8) Are nutrition, sleep pattern, and lifestyle changes effective in treatment?

Yes. Insomnia, prolonged hunger, excessive caffeine, or stress can increase the intensity of pain. Therefore, regular sleep, light exercise, healthy nutrition, and stress management are an integral part of treatment.

9) Is complete recovery possible? Is treatment promising?

Thanks to medical advances and new treatment methods, more patients are experiencing significant improvement in their pain every day. Early diagnosis, multidisciplinary approach, and personalized treatment plans increase the chance of success.

NDPH is a challenging disease for both patients and physicians with its sudden onset and persistent nature. However, with the right treatment approach, patience, and specialist team support, controlling pain and regaining quality of life is possible.

10) Promising New Treatment Approaches

Although there is still no definitive and universally accepted treatment for New Daily Persistent Headache (NDPH), recent research has brought promising new treatment approaches to the agenda. Below you can find prominent options and research data. These treatments have not yet become standard for every patient and must be evaluated by a neurology specialist experienced in headaches.

1. CGRP pathway-targeted treatments
   Case studies have reported that CGRP (calcitonin gene-related peptide) receptor antagonist monoclonal antibodies such as erenumab have been successful in NDPH subgroups with “migraine-like features.” For example, in a 46-year-old woman, continuous headache completely disappeared with erenumab and did not recur for 2 years. This may not be for all NDPH cases, but can be considered as a treatment option in the presence of “NDPH phenotype overlapping with migraine.”
2. Neuromodulation – Repetitive Transcranial Magnetic Stimulation (rTMS)
   In a recently published pilot study, three-day high-frequency rTMS application was performed on 50 NDPH patients, and ≥50% pain intensity reduction was observed in 70%. This method is non-invasive and aims to affect brain pain control pathways. However, larger, placebo-controlled studies are needed.
3. Device-based treatments (e.g., nerve stimulation)
   Studies with devices such as Nerivio, especially in pediatric-adolescent groups, are being recorded — the study titled “Nerivio Device for Treatment of New Daily Headache” is being conducted in this area. Such devices attract interest as a “non-pharmaceutical” option that can be applied during attacks or play a supporting role for daily chronic pain.
4. Supplement/additional support treatments
   Improvements in headaches with Coenzyme Q10 (CoQ10) supplementation have been reported, especially in pediatric cases. This approach is not the main treatment but can be considered as a supportive approach.
5. Lifestyle & neuro-biological targets
   Research also shows that inflammatory and neuroimmunological mechanisms may play a role in NDPH. For example, in a study examining serum cytokine levels, IL-6 was found to be high. This suggests to us that there is “a brain signaling/sensitivity change beyond pain” and supports the contribution of lifestyle changes (sleep pattern, stress control, avoiding triggers) to treatment.

Points to Consider

• These new approaches are not yet widely approved standard treatments; some studies have been conducted with a limited number of patients.
• Patients’ phenotypic characteristics (e.g., migraine history, onset trigger) may affect response and the possibility of “subtype underlying NDPH” should be considered.
• Treatment selection must be made under the supervision of a neurology specialist experienced in headaches.
• In device-based and supplement treatments, suitability for the patient should also be evaluated before use.