A 13-year-old girl you know well presents to you in mid- September for evaluation of headache. She describes throbbing pain in the bilateral frontotemporal area, sometimes spreading to the whole head. She has already missed 5 days of school because the loud noises and bright lights there make her feel worse. She tells you the pain started in early June while she was ill with a sore throat. She can recall the exact date that the headache started. Initially she and her parents thought it was a “normal headache” so they did not seek care. The headache persisted all summer, but the pain remained mild as long as she avoided physical exertion and slept 12 hours per day.
The patient and her parents deny any significant stressors, and report that her mood has been consistent with her level of pain. There is no known history of trauma, though she played competitive soccer last spring. She endorses dizziness, problems concentrating, and nausea. She is not taking any medications regularly. Her general medical and neurologic exams are normal. She has no meningismus, and her fundoscopic examination reveals normal disc margins.
Discussion: The patient has new daily persistent headache (NDPH), a descriptive diagnosis for a headache that is constant from the start and lasts for at least 3 months. NDPH is a subtype of chronic daily headache, which occurs in at least 1.5% of children. NDPH usually has some features of tension-type headache with bilateral, non-pulsatile pain, and superimposed migraine with photophobia, phonophobia, nausea, and worsening with activity. The important historical feature in NDPH is the abrupt onset of pain. This may be associated with a viral infection, extracranial surgery, or minor head trauma. Many patients report comorbid sleep disturbance, mood problems, and dizziness.
Given its abrupt onset, NDPH is a diagnosis of exclusion. Sinusitis, meningitis, tumor, idiopathic intracranial hypertension, cerebral sinus venous thrombosis, carotid dissection, and spontaneous intracranial hypotension should be considered, especially if the patient presents within 3 months of headache onset. Children who describe severe pain of maximal intensity within seconds of onset (thunderclap onset) should be evaluated emergently.
NDPH can self-resolve in a few months, or it can be refractory to treatment for years. Because we cannot predict when the headache will improve, we recommend multimodal treatment for all patients. Initial management should include reassurance, encouragement to resume normal activities (which will help to control symptoms long term), and guidance on sleep hygiene, hydration, and diet. Frequent use of analgesic medications can exacerbate the pain over time, so these should be limited to 3 days per week or less. Medications such as amitriptyline and topiramate can help to reduce the intensity of the constant headache and decrease the frequency of severe headaches, but often take several weeks to work.
References and Suggested Readings
International Classification of Headache Disorders, 2nd edition. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders, 2nd Edition. Cephalalgia 2004;24 (Suppl 1). (Available at http://bit.ly/classofheadache.)
Mack KJ. New daily persistent headache in children and adults. Curr Pain Headache Rep. 2009;13(1):47-51.
Kernick D, Campbell J. Measuring the impact of headache in children: a critical review of the literature. Cephalalgia. 2009;29(1):3-16