Diagnosis and Management of Chronic Daily Headache

Ivan Garza, M.D.; Todd J. Schwedt, M.D.


Semin Neurol. 2010;30(2):154-166. 

In This Article

New Daily Persistent Headache

New daily persistent headache, one of the most treatment refractory headaches, is a headache that begins one day and typically does not remit.[106] New daily persistent headache affects women more than men with reported ratios of 1.3:1 and 2.5:1.0 and can essentially affect all age groups.[107–109] Peak age of onset is in the second and third decades for women and the fifth decade in men.[109] Overall mean age of onset is 35 years of age.[108] Although new daily persistent headache is estimated to occur infrequently in the general population, the exact frequency is unknown.[108] In headache clinics, however, ~1 in 10 CDH patients have new daily persistent headache.[110]

The etiology of new daily persistent headache is not well understood. Although the nature of the associations is unclear, infection, flu-like illness, surgery, and stressful life events may precede new daily persistent headache.[109] How these may result in new daily persistent headache is unknown and in many patients, no precipitating factors exist.[108] Possible associations between new daily persistent headache and Epstein-Barr virus (EBV), herpes simplex virus (HSV), and cytomegalovirus (CMV) have been suggested but remain unproven.[109,111–114]


The vast majority of patients (up to 82%) can vividly recall the exact date the headache started.[109] In most, ~80%, the pain is continuous.[108,109] Pain intensity tends to be moderate, although many patients experience severe pain.[109] Clinical features vary significantly. Headaches may have primarily migraine features (photophobia, nausea, etc.) or be "featureless" and reminiscent of chronic tension-type headache.[107–109] Secondary headache disorders, including those due to spontaneous cerebrospinal (CSF) leaks and cerebral venous sinus thrombosis, need to be ruled out.[55,106] MRI of the brain with gadolinium and magnetic resonance venography (MRV) should be considered. Clinical judgment guides further investigations, if any. Current ICHD-2 diagnostic criteria for new daily persistent headache are as follows:[55]

  1. Headache for >3 months fulfilling Criteria 2 through 4

  2. Headache is daily and unremitting from onset or from <3 days from onset

  3. At least two of the following pain characteristics:

  4. Bilateral location

  5. Pressing/tightening (nonpulsating) quality

  6. Mild or moderate intensity

  7. Not aggravated by routine physical activity, such as walking or climbing stairs

  8. Both of the following:

    1. No more than one of photophobia, phonophobia, or mild nausea

    2. Neither moderate or severe nausea nor vomiting

  9. Not attributed to another disorder

Of note, although the above criteria reflect essentially a chronic tension-type headache phenotype, migrainous features are frequently reported.[115] Diagnostic criteria will likely be modified as knowledge about this disorder expands.


New daily persistent headache can endure for many years (even decades) and can be disabling. Despite proper treatment, the headache frequently does not abate.[106] Takase found treatment to be very effective in 27%, moderately effective in 3%, mildly effective in 20%, and not effective in 50% of 30 new daily persistent headache sufferers.[108] In agreement with other headache specialists,[116] we recommend classifying the dominant headache phenotype, whether it is migraine or tension-type, and treat with preventives accordingly.

New daily persistent headache has been reported to take one of the following courses: a self-limited one typically resolving without treatment within several months, or a refractory course resistant to aggressive treatment.[55] Although most patients are headache free at 2 years in some series, in others (and in practice) new daily persistent headache may be refractory to treatment for many years.[106–109,113]


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