New daily persistent headache

Matthew S Robbins MD (Dr. Robbins of Montefiore Headache Center is a site principal investigator for a clinical trial conducted by eNeura.)
Stephen D Silberstein MD, editor. (Dr. Silberstein, Director of the Jefferson Headache Center at Thomas Jefferson University, receives honorariums from Alder Biopharmaceuticals, Allergan, Amgen, Avanir Pharmaceuticals, Curelator, Depomed, Dr. Reddy's Laboratories, eNeura, electroCore Medical, Lilly USA, Supernus Pharmacerticals, Teva, and Trigemina for consulting and/or advisory panel membership.)
Originally released December 20, 2013; last updated May 26, 2015; expires May 26, 2018


New daily persistent headache is an uncommon chronic daily headache syndrome that features daily headache from the onset without any clear etiology. In this article, the author reviews the history and classification of new daily persistent headache, followed by its clinical manifestations and speculation about potential etiologies and pathogenesis. The syndrome's 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.


• The classification allows for clinical manifestations of a daily headache that resembles either chronic migraine or chronic tension-type headache.


• The prognosis is variable, and 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 characterized by the acute onset of a daily and usually continuous headache, diagnosed only after other primary headache disorders and secondary etiologies have been excluded. 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, known as the Silberstein-Lipton criteria (Silberstein et al 1994), were formulated along with the other 3 forms of primary chronic daily headache of long duration (chronic migraine, chronic tension-type headache, and hemicrania continua) in 1994. These criteria for new daily persistent headache (Table 1) specified headache with 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 patients based on the headache attack characteristics (eg, presence or absence of migraine features). The Silberstein-Lipton criteria for new daily persistent headache were a major step forward in the recognition of this syndrome, but the 1-month headache-duration requirement may have been too short, potentially leading to the inclusion of patients with secondary etiologies that have not yet remitted in such a timeframe. In addition, the average headache frequency requirement of 15 monthly days may not fully capture the essence of this condition, which usually 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 the limitations of the Silberstein-Lipton criteria, but it also created a new challenge: excluding patients who possessed too many migraine features, based on the prevailing thoughts on new daily persistent headache symptomatology by European experts.

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 new daily persistent headache series have not accepted 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) and arguing that patients who have new daily persistent headache with migraine features would otherwise be left unclassified and undiagnosed. This approach distills the essence of the diagnosis down to 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 (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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