ENESPT
NDPH

For your doctor

A one-page NDPH summary for clinicians.

NDPH is rare enough that many GPs will not have met it. Print this page and give it to the clinician you are seeing: the diagnostic criteria, what needs ruling out first, and how treatment is usually chosen — with the references to check.

One page, portrait, A4 or US Letter. Written by Seth Mundall, MD; checked against the sources listed at the bottom.

Clinical summary · for healthcare professionals

New daily persistent headache (NDPH)

ICHD-3 code 4.10 · ICD-10-CM G44.52 · Prepared by Seth Mundall, MD, for ndph.org · Reviewed October 2026

Diagnostic criteria (ICHD-3 4.10)1

APersistent headache fulfilling criteria B and C
BDistinct and clearly remembered onset, with pain becoming continuous and unremitting within 24 hours
CPresent for more than 3 months
DNot better accounted for by another ICHD-3 diagnosis

No particular phenotype is required: the pain may have migraine-like or tension-type-like features.

Key facts

  • Population prevalence about 0.03–0.1%; relatively more common in children and adolescents.2,3,40
  • About half of patients report a trigger: most often infection or a flu-like illness, then a stressful life event or surgery (all post-surgical cases in one series had been intubated).4
  • About two-thirds have a chronic-migraine-like phenotype.7
  • Among the most treatment-refractory primary headaches; no randomised trials specific to NDPH.7,40

Management principles

  • Treat according to the predominant phenotype (migraine-like or tension-type-like).40
  • Give each preventive an adequate dose and duration before judging it ineffective, and record outcomes.
  • Screen for and prevent medication overuse: acute medication on ≥10 days/month (≥15 for simple analgesics and NSAIDs).1,31
  • Options reported in refractory cases include nerve blocks, onabotulinumtoxinA, IV methylprednisolone, IV lidocaine and ketamine; evidence is limited.40
  • In children, delay to first treatment was associated with worse outcomes at one year.35
  • Consider referral to a headache specialist when the diagnosis is uncertain, red flags are present, or several preventives have failed.

Exclude secondary causes first

Clinical clueConsider
Worse upright, eased lying flatSpontaneous intracranial hypotension (CSF leak)
Worse lying down, on waking or with Valsalva; papilloedema; pulsatile tinnitus; visual obscurationsRaised intracranial pressure (idiopathic intracranial hypertension, venous sinus thrombosis, mass)
Thunderclap onsetSubarachnoid haemorrhage, RCVS, cervical artery dissection, venous sinus thrombosis
Age over 50; jaw claudication; scalp tendernessGiant cell arteritis (ESR/CRP)
Fever, weight loss, cancer or immunosuppressionInfection, malignancy
Pregnancy or post-partumVenous sinus thrombosis, pre-eclampsia
Onset after head or neck injuryPersistent post-traumatic headache
Acute medication on many daysMedication-overuse headache — establish which came first
Strictly one-sided with ipsilateral autonomic featuresHemicrania continua (indomethacin response)
Gradual build-up from episodic attacksChronic migraine or chronic tension-type headache

Diagnosis is clinical; investigation is directed at excluding the causes above and usually includes brain imaging.40

From the patient. I may have brought a headache calendar (pain by day, medication days) and a history of treatments tried. Both are free at ndph.org/tools.html.

1. Headache Classification Committee of the IHS. ICHD-3. Cephalalgia 2018;38:1-211.

2. Grande RB et al. Cephalalgia 2009;29:1149-55.

3. Castillo J et al. Headache 1999;39:190-6.

4. Rozen TD. Headache 2016;56:164-73.

7. Cheema S et al. NDPH: a systematic review and meta-analysis. Cephalalgia 2023;43:3331024231168089.

31. Diener HC et al. Medication overuse headache. Lancet Neurol 2019;18:891-902.

35. Abuhalaweh N et al. Treatment outcomes in NDPH in children and adolescents. Cephalalgia 2026;46:3331024261426562.

40. Yamani N, Olesen J. NDPH: a systematic review. J Headache Pain 2019;20:80.

References

Numbers in the text link to these sources. Where the evidence comes from migraine rather than NDPH, the text says so.

  1. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018;38(1):1-211. doi.org/10.1177/0333102417738202
  2. Grande RB, Aaseth K, Lundqvist C, Russell MB. Prevalence of new daily persistent headache in the general population. The Akershus study of chronic headache. Cephalalgia 2009;29:1149-55. doi.org/10.1111/j.1468-2982.2009.01842.x
  3. Castillo J, Muñoz P, Guitera V, Pascual J. Epidemiology of chronic daily headache in the general population. Headache 1999;39:190-6. doi.org/10.1046/j.1526-4610.1999.3903190.x
  4. Rozen TD. Triggering events and new daily persistent headache: age and gender differences and insights on pathogenesis — a clinic-based study. Headache 2016;56:164-73. doi.org/10.1111/head.12707
  5. Cheema S, Mehta D, Ray JC, Hutton EJ, Matharu MS. New daily persistent headache: a systematic review and meta-analysis. Cephalalgia 2023;43(5):3331024231168089. doi.org/10.1177/03331024231168089
  6. Diener HC, Dodick D, Evers S, et al. Pathophysiology, prevention, and treatment of medication overuse headache. Lancet Neurol 2019;18:891-902. doi.org/10.1016/S1474-4422(19)30146-2
  7. Abuhalaweh N, Gelfand AA, Evans M, et al. Treatment outcomes in new daily persistent headache in children and adolescents. Cephalalgia 2026;46:3331024261426562. doi.org/10.1177/03331024261426562
  8. Yamani N, Olesen J. New daily persistent headache: a systematic review on an enigmatic disorder. J Headache Pain 2019;20:80. doi.org/10.1186/s10194-019-1022-z