New Daily Persistent Headache
I remember exactly the day my headache started. Before that, I hardly ever had headaches. But since that day, I’ve had one 24/7. What do I do? Headaches that come on suddenly and don’t go away can be scary and challenging to treat. This 15-year-old girl, who came to our clinic with her mother, made it easy for us to diagnose her condition by remembering exactly when her headaches began. Chronic daily headaches can begin two ways: 1. The child starts getting more frequent headaches over a period of time, going from one headache a week to three a week to almost daily. This form of chronic daily headache can evolve from tension-type headache or episodic migraine. 2. The headache begins abruptly and within 72 hours of onset becomes unremitting. There is no history of an escalating pattern of headaches as with the previous form. This form is called New Daily Persistent Headache (NDPH). In either case, the characteristics are similar: typically pain on both sides of the head (bilateral), pressing or tightening quality, mild-to-moderate intensity, and not aggravated by routine physical activity. Occasionally people with NDPH also have features similar to a migraine, including pounding pain, nausea or vomiting, and light and/or sound sensitivity. Our 15-year-old patient’s ability to pinpoint the exact date her headaches began makes clear it’s NDPH. She describes the pain of her headaches as pressing and pounding. It can fluctuate and improves with sleep. After three months with NDPH, she’s missed 17 days of school, tried two preventive medicines without success, and stopped using over-the-counter (OTC) medicines because they were not effective. While people with NDPH typically remember exactly when their headache started, why they start is often a mystery. It’s been suggested that for about 50% of cases there is a precipitating cause or association, such as a viral infection, mononucleosis, surgery, trauma (such as minor head trauma or injury to other parts of the body) or an intense emotional event. NDPH is more common in teens than older people and more common in females than males. Of 89 pediatric patients with chronic daily headache seen at the Cleveland Clinic, 38 had NDPH. The percentage of adult chronic headache sufferers with NDPH is typically closer to 11%. Needless to say, a thorough evaluation must be done to first rule out any underlying condition. These conditions can include increased or low cerebrospinal fluid pressure, trauma, tumor, infection, sinus disease, temporomandibular joint syndrome (TMJ), vascular disorders, hormonal changes, psychological stress and pseudotumor (an abnormality, such as a temporary swelling, that resembles a tumor). The child’s healthcare provider should take a thorough history, and do both a general physical evaluation and a detailed neurological evaluation. The first phase of treatment involves patient and parent reassurance and education. Patients need to keep a regular sleep schedule, drink plenty of fluids, exercise and eat a healthy diet. If the child is overweight (Body Mass Index greater than 25), a weight loss program should be initiated. They should also avoid missing school and, if they are taking OTCs more than two times per week, they must discontinue using them. The most difficult-to-treat patients are those who have missed excessive amounts of school, those who have overused pain medications, those with psychiatric disorders, and straight-A students, who often experience higher levels of stress because of their own high expectations of themselves. Studies have yet to show that any one treatment approach is significantly better than any other. A number of complementary and alternative methods are worth trying, including riboflavin, butterbur, coenzyme Q10, magnesium, biofeedback, physical therapy and acupuncture. Medications that are often used include the tricylic antidepressants (in particular, amitriptyline), topiramate, valproic acid, gabapentin, the SSRI class of antidepressants, Botox® and indomethacin. No long-term studies have determined the ultimate outcome for most kids with NDPH. It’s believed, however, that about 30% get better in three to four months even without intensive treatment. The rest remain with chronic daily headache, which can be quite difficult to treat. Still, over 85% will be headache-free within two years. Those kids who do not improve may need to consider inpatient treatment at a headache clinic. —A. David Rothner, MD, Director of the Pediatric Headache Clinic and Director Emeritus of Child Neurology at the Cleveland Clinic Foundation in Cleveland, Ohio |
