New Daily Persistent Headaches

New daily persistent headache (NDPH) is a primary headache disorder. It is unrelated to any other condition or disorder.


It can occur at any age from childhood to 70s, with the average age of onset of about 35. It is two to three times more common in women, and almost half of those with NDPH have a family history of some headache disorder. It is characterized by new onset headaches, of which there is no prior history. These headaches have an increasing frequency. Patients clearly remember when these start occurring. And since the onset, they occur on a daily basis and persist for over 3 months with continuous pain. The headaches resemble those of a migraine, in terms of being associated with light or sound sensitivity, nausea, and throbbing pain. Alternatively, they may resemble a tension-type headache.
Although, in half of the cases they are triggered by surgery or infection, in others there is no clear trigger.


People with NDPH should be carefully assessed for an underlying cause, and other primary headache disorder should be ruled out, such as chronic migraine, chronic tension-type headache, hemicrania continua, or medication overuse headache. NDPH can be distinguished from those as there is characteristically no prior history (newness of onset) and that these patients remember when they started occurring. The increasing frequency of headaches eventually leads to daily, continuous headache.

Other conditions that give a similar presentation of persistent headaches include stress, dehydration, anemia, other chronic conditions (like diabetes, lupus, etc.), low estrogen levels (PMS-related headaches), sinus problems (associated with fever, phlegm), chronic sleep deprivation, and in rare cases, brain tumor. But more commonly, taking too much caffeine or headache pills can also cause persistent headaches.

Investigations often include lab tests, imaging and lumbar puncture (with opening pressure) to exclude metabolic, infectious or inflammatory conditions. The most important differential diagnosis to exclude is pseudotumor cerebri, CSF leak, and cerebral venous sinus thrombosis. Headaches related to CSF pressure are typically affected by body position – a careful history taking on that point is essential.

NDPH can be difficult to treat as there are no specific treatments for it. For the most part, it can be treated like chronic migraine. Sedative analgesics should be avoided due to their addiction potential.

In a recent publication, osteopathic manipulative treatment was shown to successfully manage new daily persistent headache and severe somatic dysfunction had a resolution of her pain after osteopathic manipulative treatment.

It is being suggested that a combination of healthy lifestyle with exercise, good diet, and regular sleep, along with taking regular headache medicines and addressing comorbidities, such as hypertension may be the right approach. Antidepressants that target pain receptors such as amitriptyline, nortriptyline, or venlafaxine, or antiseizure medications such as topiramate, or use of OnabotulinumtoxinA (Botox) may have some benefit. Other nonpharmacologic treatments, such as biofeedback, behavioral treatment, and relaxation therapy may also be helpful in mitigating this condition.