new daily persistent headache

New daily persistent headache 2021 updated

New daily persistent headache is a type of headache that is a primary headache disorder. Primary headache disorders are a group of headaches where the headache is not caused by other conditions.

A new daily persistent headache was previously known as a chronic headache with acute onset. In 1986, Vanast first described new daily persistent headache as a benign headache syndrome that usually goes away without treatment.

New persistent headache symptoms:

New daily persistent headache has typical features that help to distinguish it from other types of headache. These characteristic features are

It is new in onset-

It means that it occurs in a person who does not have a history of headache previously. If the person has a history of headache, then the headache should not have increasing frequency before it occurs, only then it can be a new daily persistent headache.

Also, patients with a previous history of headache should not have exacerbation associated with it. It should not be followed by medication overuse.

Occurs daily-

The headache occurs daily. The headache occurs more than 4 hours daily. The headache begins acutely and reaches its peak within 24 hours. Sometimes the pain reaches at its peak within 3 days.

Headache starting time is distinctive-

The person with a new daily persistent headache can distinctly and clearly remember the time or exact date and circumstances when the headache starts.

Duration of headache-

The headache present for more than three months.

Headache characteristics-

So it is a persistent headache, occurs daily and the person can clearly remember the time of the starting of the headache. The pain lacks characteristic features and the pain can be migraine-like or tension-type like and sometimes may have characteristics of both.

The pain in new daily persistent headache is dull type and sometimes throbbing type of pain the patient may feel.

New daily persistent headache sometimes mimics migraine, when it has light or sound sensitivity, nausea, throbbing pain. New daily persistent headache may also mimic tension-type milder headache without having light or sound sensitivity.

New daily persistent headache causes:

New daily persistent headache is a clinically distinct syndrome and has important primary and secondary causes.

Primary Cause-

The primary causes are migrainous type and featureless tension-type.

Secondary cause-

The secondary causes are

  1. Subarachnoid hemorrhage
  2. Low cerebrospinal fluid volume
  3. Raised CSF pressure
  4. Post-traumatic headache
  5. Chronic meningitis

Here it is important to mention that subarachnoid hemorrhage is the most serious secondary cause and must be ruled out by history and medical investigation.

Other causes-

  1. About 50 percent of new daily persistent headache occurs after surgery and sometimes associated with an infectious illness. The one main cause of sudden rise of new daily persistent headache is due to covid 19 virus. Other viruses that may cause new daily persistent headache are epstein barr virus, herpes simplex virus, and cytomegalovirus. So many times new daily persistent headache are seen after flu like illness.
  2. Underlying medical condition causes new daily persistent headache. Side by side it is also true that sometimes stressful life events can also cause it.
  3. Cervical spine joint hypermobility may be a contributing factor for the development of new daily persistent headache.

New daily persistent headache risk group:

This headache is more commonly occurs in females, occurs mostly in the 2nd to 3rd decade of life. But it might also occur in children.

New daily persistent headache difference from other headaches (differential diagnosis):

People with a new daily persistent headache need thorough medical evaluation. Because sometimes there is an underlying medical condition(s) that causes it. Sometimes there are stressful life events that may cause new daily persistent headache. Medical evaluation helps to confirm that the headache is not of another primary type. The primary headache disorder commonly mistaken as new daily persistent headache is – chronic migraine, chronic tension-type headache, hemicrania continua, medication overuse headache. But in these later cases, the person usually complains about the increasing frequency of pain with time.

If a patient has a chronic migraine and chronic tension-type headache features, then if new daily persistent headache characteristics are present then the diagnosis is new daily persistent headache.

But if the patient has both the characteristic of new daily persistent headache or hemicrania continua, then the diagnosis is hemicrania continua.

If a patient has a history of medication overuse and has the characteristic feature of new daily persistent headache, then it will be diagnosed as a new daily persistent headache only when the starting of daily occurrence of headache is clearly and definitely before medication overuse. Otherwise, the diagnosis will be both new daily persistent headache and medication overuse headache.

Headache due to other causes ( also known as secondary headache) such as acute headache due to traumatic injury to the head, headache due to increased cerebrospinal fluid pressure, headache due to low cerebrospinal fluid pressure must be ruled out before finally concluding any headache as new daily persistent headache.

New daily persistent headache types:

New daily persistent headache are of two types

Self limiting-

In the self-limiting type, this new daily persistent headache goes away within few months without therapy.

Resistant type-

In resistant type, the headache does not go away and the headache is not responsive to treatment, even aggressive treatments also fail to give good results.

New daily persistent headache diagnosis:

To diagnose a new daily persistent headache, one needs to consider the following things in mind.

Proper medical history-

A new daily persistent headache normally occurs in a person with no previous history of headache. Also, the pattern of pain in new daily persistent headache is that pain not increases with time, though the pain presents more than 4 hours a day. So proper history about the time of starting of pain, character of pain, duration of pain, any previous history of headache, etc . are very important before diagnosing it as a new daily persistent headache.

Diagnostic tests –

Investigations include a blood test, brain and vessel imaging, and sometimes lumbar puncture ( spinal tap ) with opening pressure.

Ruling out other similar conditions –

The condition must be ruled out from other primary headache disorders. As new daily persistent headache frequently mimics other primary headache disorders, so it is very important to rule out other conditions before final diagnosis as new daily persistent headache.

Exact cause finding –

Metabolic, inflammatory, or any infectious condition may be the cause of new daily persistent headache. So finding the cause is very important.

CSF pressure diagnosis –

Cerebrospinal fluid (CSF) pressure (either high or low) and cerebral venous sinus thrombosis, cause a headache that may be mistaken as a new daily persistent headache.

But headache due to CSF pressure issues is usually affected by body position ( such as spontaneous CSF leak cause low CSF volume headache that comes when one sits  or stands in the upright position and improves or goes away on lying down in supine position or reclining, this chronic low CSF volume headache typically not present on waking but worsens during the day). 

On the other hand, raised CSF pressure headache has a typical history of generalized headache which is present on waking but improves as the day goes on.

So thorough history is of utmost important to know if the headache was affected by body position or not. Cerebral venous sinus thrombosis presents headache mostly as raised intracranial pressure with worsening of the headache on Valsalva maneuvers.

Additionally patient may also have seizures, altered consciousness level, or other neurological problems.

New daily persistent headache treatment:

The new daily persistent headache in many cases goes away within 3- 5 years. Sometimes the headache is disabling also. This headache is treated just like chronic migraine or chronic tension-type headache.

New daily persistent headache medicines-

It is indeed a challenge for the doctor to treat new daily persistent headache, but people can get relief by taking medications.

  • Tricyclic antidepressants- mostly amitriptyline
  • Anticonvulsants such as topiramate, valproate, and gabapentin have shown good results.
  • Sometimes the monoamine oxidase inhibitor such as phenelzine may be used.

People should avoid taking acute medications and barbiturates and narcotics also should be avoided to reduce the chance of developing medication overuse headache.


Clinically,it is seen that spontaneous recovery of new daily persistent headache may occur. But many cases are there where new daily persistent headache is not responsive to standard headache therapies.

The actual diagnosis of new daily persistent headache is very important because there are many other conditions that can be mistaken as new daily persistent headache. In similar way, there are many clinical conditions that show new daily persistent headache as a symptom, so thorough investigation is needed. Stay healthy and happy.


  1. International Headache Society
  2. Harrison’s Principles of Internal Medicine 20/E, page 87, page 88 and page 89
  3. American Migraine Foundation
  4. American Headache Society
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