New daily persistent headache

Thomas Berk MD (Dr. Berk of the NYU School of Medicine has no relevant financial relationships to disclose.)
Stephen D Silberstein MD, editor. (Dr. Silberstein, Director of the Jefferson Headache Center at Thomas Jefferson University, receives honorariums from Allergan, Avanir Pharmaceuticals, Curelator, Depomed, Dr. Reddy's Laboratories, eNeura,  INSYS Therapeutics, Lilly USA, Supernus Pharmacerticals,  Thernica and Trigemina for consulting. He is also the  principal investigator for a clinical trials conducted by Alder Biopharmaceuticals, Amgen, electroCore Medical, Lily USA and Teva.)
Originally released December 20, 2013; last updated May 10, 2017; expires May 10, 2020


New daily persistent headache is a unique daily headache syndrome that is characterized by a near continuous headache at onset with no clear etiology. In this article, the author reviews the history and classification of new daily persistent headache, followed by its clinical manifestations as well as potential etiology and pathogenesis. The differential diagnosis, workup, prognosis, and management are also addressed.

Key points


• New daily persistent headache is a daily headache syndrome that starts acutely and can only be diagnosed after 3 months have elapsed and other secondary and primary headache diagnoses have been excluded.


• There are 2 subtypes based on the clinical features of headache–migrainous or nonmigrainous (features of tension-type headache).


• The prognosis varies; however, the treatment approach is largely extrapolated from the management of other forms of chronic daily headache.

Historical note and terminology

New daily persistent headache is a unique headache disorder characterized by the acute onset of a daily and usually continuous headache, diagnosed only after the exclusion of other primary headache disorders and secondary etiologies. Historically, new daily persistent headache was first described by Walter J Vanast at the 28th annual meeting of the American Association for the Study of Headache (Vanast 1986). Although his case series of 45 patients was presented in 1986, the first edition of the International Classification of Headache Disorders (ICHD-1) did not include this syndrome (Headache Classification Committee of the International Headache Society 1988).

The first diagnostic criteria of chronic headache disorders, the Silberstein-Lipton criteria (Silberstein et al 1994), were formulated to characterize 3 forms of primary chronic daily headache: chronic migraine, chronic tension-type headache, and hemicrania continua, in 1994. These criteria specified new daily persistent headache (Table 1) as having an average frequency of 15 or more days per month for at least 1 month, developing acutely, not attributable to any other cause, and without a background of escalating migraine or tension-type headache. The criteria did not exclude or subclassify patients based on clinical characteristics of the headache (eg, presence or absence of migraine features). The Silberstein-Lipton criteria were a major step forward in the recognition of this syndrome, but the details were still subject to significant debate. For instance, the 1-month headache-duration requirement was considered by many to be too short, as it could potentially lead to the inclusion of patients with secondary etiologies that have not yet remitted in such a limited timeframe. In addition, the average headache frequency requirement of 15 monthly days did not fully capture the essence of this condition, which typically features daily and continuous head pain.

Table 1. Silberstein-Lipton Criteria for Diagnosis of New Daily Persistent Headache

(A) Average headache frequency 15 days/month for >1 month

(B) Average headache duration 4 hours/day (if untreated). Frequently constant without medication but may fluctuate

(C) No history of tension-type headache or migraine which increases in frequency and decreases in severity in association with the onset of NDPH (over 3 months)

(D) Acute onset (developing over <3 days) of constant unremitting headache

(E) Does not meet criteria for hemicrania continua

(F) Not attributed to another disorder

(Silberstein et al 1994)

The second edition of the International Classification of Headache Disorders (ICHD-2) included new daily persistent headache and led to its more widespread recognition as a headache syndrome (Table 2) (Headache Classification Committee of the International Headache Society 2004). It addressed some of the limitations of the Silberstein-Lipton criteria, but it excluded patients who possessed a number of features of migraine.

Table 2. International Classification of Headache Disorders (2nd Edition) Criteria for New Daily Persistent Headache

(A) Headache for more than 3 months fulfilling criteria B-D
(B) Headache is daily and unremitting from onset or less than 3 days from onset
(C) At least 2 of the following pain characteristics:


(1) Bilateral location
(2) Pressing/tightening (non-pulsating) quality
(3) Mild or moderate intensity
(4) Not aggravated by routine physical activity such as walking or climbing stairs

(D) Both of the following:


(1) No more than 1 of photophobia, phonophobia, or mild nausea
(2) Neither moderate or severe nausea or vomiting

(E) Not attributed to another disorder

(Headache Classification Committee of the International Headache Society 2004)

Subsequent case series of new daily persistent headache did not accept such restrictive criteria and have been more inclusive, omitting ICHD-2 criteria C and D (Kung et al 2009; Robbins et al 2010; Monzillo and Nemoto 2011; Peng et al 2011; Li et al 2012; Prakash et al 2012). Many argued that patients who have new daily persistent headache with features of migraine would otherwise be left unclassified and undiagnosed; rather, the entity of new daily persistent headache began to be simplified as the presence of a continuous daily headache that starts acutely, without any clear secondary cause, and persists for at least 3 months. The 3rd beta edition of the ICHD (ICHD-3 beta) (Headache Classification Committee of the International Headache Society 2013) now accepts this approach and features revised diagnostic criteria that do not specify a necessary headache phenotype or other clinical features (Table 3).

Table 3. International Classification of Headache Disorders (3rd Edition beta) Criteria for New Daily Persistent Headache

(A) Persistent headache fulfilling criteria B and C
(B) Distinct and clearly remembered onset, with pain becoming continuous and unremitting within 24 hours
(C) Present for more than 3 months
(D) Not better accounted for by another ICHD-3 diagnosis

(Headache Classification Committee of the International Headache Society 2013)

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