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Adina Taylor

Professor Kari Carter

ENG 1201

30 April 2021

Researched Argument Essay

It all began after a violin and piano audition on a cold, Saturday morning, my junior year

of high school. Stepping outside with the audition behind me, I shivered as I climbed into the car.

That moment of sitting down in the car marked the onset of the headache and would be replayed

in my mind for years. This headache presented itself like no other; the pressing and pulsating

quality felt as if I was being crushed on the top of my head and getting stabbed with needles

simultaneously. The headache persisted from that moment onward. Days went by, tests came

back normal, treatments failed, doctors conceded, and no answer revealed itself as to why the

headache refused to leave. I fought hard to keep it from taking over my life, still performing in

orchestra, playing for special events, graduating from high school, and starting college as a

music major. After three years of having a constant headache and seeing more than twenty

doctors and specialists, a diagnosis was given at last. The headache had a name: New Daily

Persistent Headache.

New Daily Persistent Headache (NDPH) needs to be researched to a greater extent

because it is the most refractory headache condition with no cure or known effective treatments,

greatly affecting the lives of people given this diagnosis. The rare headache condition of NDPH

falls into the category of chronic daily headaches. The sudden onset followed by a 24/7,

unremitting headache sets NDPH apart from other chronic headaches (Rozen). Most patients can
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recall the exact time of the headache onset, which is unique from any other headache condition

(Palacios-Ceña). Though NDPH has been researched and clinical studies have been performed

by a few doctors and researchers, this diagnosis remains an enigma for doctors and patients alike.

The New Daily Persistent Headache diagnosis used to be described as a benign headache

condition that would resolve itself in most cases, but it necessitates further research since this has

been found to not be the case. NDPH was first described in 1986, when neurologist Dr. Walter J.

Vanast concluded that it was a headache syndrome that would subside on its own (Tyagi).

Following studies showed this to be an incorrect description of the NDPH diagnosis, as it

remains one of the most difficult headaches to treat and is unresponsive to even the most

aggressive headache treatments.

New Daily Persistent Headache is considered to be a primary headache, though

secondary headache conditions may mimic it (Rozen). Since it is a primary headache, it cannot

be caused by any underlying health conditions. The difficulty in understanding whether patients

have NDPH or a mimicking headache condition shows the need for a more comprehensive

understanding of this diagnosis, calling for further research to be done. Patients diagnosed with

New Daily Persistent Headache have to meet certain criteria in order for secondary chronic

headache conditions to be ruled out. In Neurology India, Uniyal et al. describes the NDPH

diagnosis, identifying the reason, pathophysiology, history, and treatment of the diagnosis.

Uniyal et al. discusses secondary headache conditions that mimic NDPH and explains how to

rule out these conditions in patients presenting with a chronic daily headache.

Even though New Daily Persistent Headache is distinguished for being a primary

headache condition, it can be reasoned that triggering events may cause the onset of NDPH in

many patients (Rozen). Patients studied with the diagnosis have listed triggering events
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occurring before the headache onset, such as surgery, procedures, infections, illnesses,

psychological stress, and mild trauma (Palacios-Ceña et al.). Dr. Todd Rozen, the doctor most

renowned for his studies and research on the NDPH condition, elaborates on how triggering

events might lead to the onset of NDPH in his study. Less than 50% of patients presenting with

NDPH recall a triggering event occurring prior to headache onset, such as a surgery, infection,

illness, stressful life event, hormonal manipulation, medication exposure, chemical exposure,

massage treatment, and loss of consciousness (Rozen). The most significant triggering event is

an infection prior to headache onset, specifically from viruses such as the Epstein-Barr virus,

followed by the triggering event of cervical injury due to hypermobility (Riddle et al.). The

multitude of triggering events that can cause patients to develop NDPH makes properly

diagnosing and treating patients difficult due to the lack of studies performed and research done

on the headache condition. With a greater knowledge of the various ways NDPH can start,

doctors would have an easier time caring for NDPH patients.

The various forms of New Daily Persistent Headache can be classified in a few ways; one

classification is by the duration of the chronic headache. The three subforms of NDPH are

remitting, relapsing-remitting, and persisting (Tyagi). Although the remitting form subsides

within two years on its own, regardless of treatment methods used, the other two subforms prove

to be difficult to treat and severely impact the life of patients. The relapsing-remitting form

leaves, but then returns intermittently. The persisting form, which is the most refractory, or

resistant to treatment, continues for years in many patients despite the most aggressive treatments

(Uniyal et al.). In order to understand the difference between these subforms and properly treat

patients with the relapsing-remitting and refractory forms, more research needs to be done.

Rozen outlines the New Daily Persistent Headache diagnostic criteria in 2011, which the
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International Headache Society has accepted (Uniyal et al.). According to the criteria listed, the

constant, unremitting headache has to have an acute onset and be present for greater than three

months (Uniyal et al.). The average headache duration has to be more than four hours per day.

While a prior history of other headache disorders does not disqualify the diagnosis, there can be

no headache history of increasing frequency of either migraine or tension headache (Rozen). The

headache has to be of a pulsating or pressing/tightening quality; has to be at a mild, moderate, or

severe pain level; has to have a bilateral or unilateral pain location; and possibly has to be

aggravated by routine physical activity (Rozen). It can present with nausea and / or vomiting;

phonophobia, which is sound sensitivity; and photophobia, which is light sensitivity; and cannot

fit the criteria for hemicrania continua, which is a severe headache condition affecting one side

of the head. Upon meeting all the above criteria and the ruling out of secondary conditions, a

patient may be diagnosed with NDPH.

While there are no known effective treatments for New Daily Persistent Headache,

doctors and headache specialists typically have patients follow a treatment plan that most

accurately aligns with their primary symptoms, which is whether the headache more closely

resembles chronic tension headache or chronic migraine (Riddle et al.). Doctors treat patients

with a headache more resembling a chronic tension headache with physical therapy, massage

therapies, muscle relaxers, chiropractic care, and osteopathic manipulation (Uniyal et al.). These

therapies may help with pain management or possibly reduce the headache, but most of the time

do not greatly benefit the patient. This leaves patients with tension-like NDPH struggling as they

exhaust all recommended treatment options without getting much or any relief. Patients with a

headache similar to a migraine headache are given various types of migraine medications.

Medications typically given to help relieve NDPH are antidepressants, antiseizure medications,
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triptans, muscle relaxants, nonsteroidal anti-inflammatory drugs, nerve blocks, calcitonin gene-

related peptide blockers, and selective serotonin reuptake inhibitors (Uniyal et al.). Again,

patients usually go through many of these medications without much benefit since the

medications are formulated for migraine, not NDPH. Treatments such as Botulinum toxin A,

Intravenous subanesthetic ketamine, and intravenous methylprednisolone are used on refractory

forms of NDPH (Uniyal et al.). The study by Riddle and Smith explains the diagnosis of NDPH,

formulates a diagnostic treatment approach, and investigates potential treatments for patients

(Riddle et al.). This study expounds on how treatments should be driven by the presenting

phenotype of the headache, as some medications and treatments may be more effective for a

headache resembling a migraine or a chronic tension headache (Riddle et al.). Though doctors

often take this approach, it is not the most effective in treating NDPH patients. With more

research performed on effective treatments for NDPH, doctors and patients would have a less

complicated and more effective treatment plan.

Having New Daily Persistent Headache can adversely affect every part of the life of a

patient, making everyday activities challenging. Sufferers with NDPH often struggle with

insomnia, depression, anxiety, and chronic fatigue, along with the presenting symptoms of

nausea, phonophobia, and photophobia (Palacios-Ceña et al.). Living with NDPH impacts

routine work, hobbies, travel, and exercise for most patients with the condition and makes

keeping a job and staying healthy quite difficult. The headache can be exacerbated by the mildest

activity, such as walking or climbing the stairs (Rozen). Having an unremitting headache makes

functioning in most environments difficult, as the headache can respond unpredictably to

different situations (Palacios-Ceña et al.). The sensitivity to light and sound, as well as nausea

and vomiting, can render patients incapacitated when the headache and accompanying symptoms
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are severe. The feeling of hopelessness and exhaustion, coupled with anxiety and fear that the

pain will never go away, also affects many patients. As more studies are performed on

psychiatric qualities in patients presenting with NDPH, it will be better understood how to treat

patients with this diagnosis (Uniyal et al.). Further research on NDPH will make the everyday

lives of patients more manageable.

One reason necessitating further research encountered in these five studies on New Daily

Persistent Headache is the small number of patients with the diagnosis that have been studied.

NDPH proves itself difficult to study because of the rarity of this headache type and the

perplexing way in which it presents itself. When Vanast first presents NDPH to the American

Headache Society in 1986, he has case studies from 45 patients with the diagnosis (Uniyal et al.).

Most studies on NDPH have approximately 12-18 patients, which does not give a broad enough

scope of the diagnosis. Rozen performed the broadest study on NDPH since he utilized the

medical records of 97 patients at a headache clinic (Rozen). The research study conducted by

Palacios-Ceña et al. in Spain on NDPH focuses on 18 patients attending the Neurology

Department Headache Units at the hospital in Valladolid and the hospital in Madrid. The 18

patients presented with NDPH range ages 18-65 years old (Palacios-Ceña et al.). Tyagi, in the

Department of Neurology at the Institute of Neurological Sciences in Glasgow, UK, reveals in

his research article that only two population studies have ever been performed on NDPH, one in

Spain and the other in Norway (Tyagi). It is difficult to understand more about such a perplexing

headache condition when only a minute fraction of patients presenting with chronic daily

headaches can be diagnosed with NDPH. Studies performed on a broader scope of patients

presenting with the diagnosis would greatly improve the understanding of NDPH.
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The lack of a medical understanding of this diagnosis leads to the reasoning that New

Daily Persistent Headache needs to be further researched in order to effectively treat patients

diagnosed with this headache condition. With rare diagnoses like NDPH, doctors and patients

alike are not equipped with the information necessary to understand and treat their chronic pain.

Many doctors have not heard of or are not familiar with NDPH and other rare diagnoses. Doctors

that have heard of the diagnosis still have a difficult time treating patients since so little is known

about NDPH and other rare diagnoses.

It may be argued that it would be difficult and expensive to formulate a medical research

study analyzing a large group of patients with NDPH. Conducting qualitative medical research

through observational studies such as a cohort study costs a large sum of money and a great

amount of time (LaMorte). Medical research studies require designing and meeting approval by

the International Review Board. Once the research study has been formulated and approved, it

still may require additional modifications. During the study, the IRB continues to review and

approve the study annually until completion. The study may be published after completion if

consistent with the research plan approved by the IRB (UW Medicine).

Though medical studies may require a lot of work and sufficient funds, the cost is worth

it for the improvement in the quality of life for NDPH patients. Formulating a research study on

New Daily Persistent Headache would not be a simple task, but the lack of information known

on this diagnosis necessitates action. Doctors treating patients with the diagnosis require the

understanding to accurately assess each patient and develop an effective treatment plan. Patients,

such as myself, would greatly benefit from having doctors with sufficient knowledge on our

diagnosis, as well as having more research studies to examine in pursuing our own treatment

plans.
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It felt bittersweet to receive the diagnosis of New Daily Persistent Headache. No longer

am I alone, a perplexing enigma of a case, yet I also have the rarest, most refractory headache

condition that exists. On top of that, doctors, researchers, and scientists know little about the

diagnosis due to the scarcity of patients diagnosed with and studies performed on the condition.

Although it is highly probable that the headache will be with me for life, the innate desire to find

the underlying cause drives me to continue reading medical articles, keeping meticulous records

of my triggers, searching for effective treatments, and asking my doctors all the questions.

Trying and failing treatments can be difficult in many ways, but the constant pain drives me to

keep searching for something that will bring relief. This diagnosis has not taken away my hope

of living a fulfilled life and one day feeling better. Over five years after the onset of the

headache, I do not have an answer as to why I have the headache, nor have I found a miracle

treatment. What I have found is a supportive community of people with the same diagnosis, a

network of doctors and therapists willing to learn along with me, and an ever-growing desire to

bring awareness to NDPH and other rare health conditions.

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Works Cited

Baker, Mitzi. “UCSF Researchers Describe Their Painful Progress.” Synapse, 22 Sept. 1994.

Synapse Archive, synapse.library.ucsf.edu/cgi-bin/ucsf?a=d&d=ucsf19940922-

01.2.2&e=-------en--20--1--txt-%22chronic+headache%22-----txIN--.

Grosberg, Brian M., et al. Headache. Wiley, 2013. EBSCOhost,

search.ebscohost.com/login.aspx?

direct=true&db=cat02507a&AN=ohiolink.b33544721&site=eds-live.

“Institutional Review Board (IRB) Approval Informationsteps.” University of Washington

Medicine Health System, Department of Anesthesiology and Medicine,

depts.washington.edu/anesth/research/irb/steps.shtml.

LaMorte, Wayne W. “Cohort Studies.” Advantages and Disadvantages of Cohort Studies,

Boston University School of Public Health, 2016, sphweb.bumc.bu.edu/otlt/mph-

modules/ep/ep713_cohortstudies/EP713_CohortStudies5.html.

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Experiences of Patients with New Daily Persistent Headache.” Headache: The Journal of

Head & Face Pain, vol. 60, no. 1, Jan. 2020, pp. 124–140. EBSCOhost,

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Headache Society, 2016, americanheadachesociety.org/wp-

content/uploads/2020/09/AHS-Fact-Sheet_NDPH.pdf.

Rozen, Todd D. “New Daily Persistent Headache: Clinical Perspective.” Headache, vol. 51, no.

4, Apr. 2011, pp. 641–649. EBSCOhost, doi:10.1111/j.1526-4610.2011.01871.x.

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issn=0028-3886;year=2018;volume=66;issue=3;spage=679;epage=687;aulast=Uniyal.

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