NDPH
Treatment
NDPH treatment: what has been tried, and what the evidence shows.
There is no treatment proven to work for NDPH, and anyone who promises one is ahead of the evidence. But there are real options, and some studies now give honest numbers. Here they are, in plain language.
The short version
- No randomised trial has been done in NDPH. Doctors borrow treatments from the headache that NDPH most resembles, usually chronic migraine or chronic tension-type headache.40
- NDPH is one of the hardest headaches to treat.7 In the best recent studies, the newer treatments helped roughly one person in three or four — fewer than in chronic migraine.42,44
- Some people do improve, sometimes a lot. Following 71 people over time, one study found three patterns: headaches that persisted, headaches that went away, and headaches that went away and came back.39
- Trying treatments one at a time, properly, is the way forward — and keeping a record so nothing that failed gets repeated.
First: make sure it is NDPH
A daily headache that starts suddenly can also be caused by something treatable, such as a spinal fluid leak, raised pressure inside the head or a problem with a blood vessel. NDPH is only diagnosed once those have been ruled out.1 Frequent painkiller use can add a second headache on top, so that is checked too.31 The clinician summary lists what doctors look for.
How a preventive is usually chosen
Because there are no NDPH-specific medicines, the choice depends mostly on what the headache looks like.40 About two thirds of people with NDPH have migraine-like features, such as throbbing pain, nausea or sensitivity to light.7 Their doctor will usually start with migraine preventives. When the pain is more like a tight band with few migraine features, tension-type headache preventives are tried. Other health problems, side effects and personal preferences narrow the choice further.
In one study of 63 patients in India followed for a median of nine months, 37% had an excellent response and another 30% a good one. Patients with a recognised trigger did better, and so did those treated with intravenous methylprednisolone or sodium valproate.48 The study looked back at records and had no comparison group, so it shows that improvement is possible, not which drug causes it.
Treatments studied in NDPH
“Response” in these studies usually means at least a 30% drop in the number of moderate-to-severe headache days. None of them compared the treatment with a placebo.
| Treatment | What the NDPH studies found | How strong is the evidence? |
|---|---|---|
| OnabotulinumtoxinA (Botox) | In 58 people with NDPH given two rounds of injections, 34.5% responded at 24 weeks. That was not significantly different from chronic migraine, and side effects were similar, with none serious.42 In a smaller US series, about half of 16 patients had fewer headache days at 6 months.43 | Moderate: the largest NDPH data for any treatment, but observational |
| CGRP antibodies (erenumab, galcanezumab and others) | In 48 people with treatment-resistant NDPH, 23% responded at 12 weeks, fewer than in chronic migraine. About half had a side effect, almost always mild.44 In a UK audit of 82 people with sudden-onset, unremitting headache (mostly NDPH or post-traumatic headache), 35% were still on erenumab after about two years because it helped.45 | Moderate: consistent, but observational |
| Nerve blocks | Blocks of the nerves of the scalp are widely used for chronic headaches, and some people with NDPH find them helpful. But in one clinic, among people who had not responded to a single greater occipital nerve block, only 10% of those with NDPH responded to blocks of several head nerves, compared with 49% in chronic migraine.46 | Low |
| Steroids (intravenous methylprednisolone) | Nine people whose headache began weeks after an infection all improved after five days of intravenous steroids.47 In children, short “bridge” treatments such as intravenous medicines, sometimes with oral steroids, helped 57% of those who had them.35 | Low: small, uncontrolled |
| Ketamine infusions in hospital | In 77 people with chronic migraine or NDPH who had failed everything else, a ketamine infusion lowered pain in 71% by the time they left hospital, but only about a quarter of those kept the benefit at their next visit.49 | Low: short-lived benefit for most |
| Occipital nerve stimulation (an implanted device) | Only one of nine people with migraine-like NDPH responded, after a median follow-up of more than four years.50 | Low, and not encouraging |
| Other medicines | Many other drugs have been reported to help single patients or very small groups. That is not enough to know whether they work.40 | Very low |
On a phone, scroll the table sideways.
Treatments that are not medicines
Living with constant pain affects sleep, mood and energy, and those in turn make pain harder to bear. Psychological approaches, especially acceptance and commitment therapy, have good evidence in chronic pain in general.30 They are not a sign that the pain is “in your head”. Sleep matters too: see sleep and a daily headache. The main guide covers supplements, diet and movement, with what the evidence does and doesn’t show.
How to get the most out of each attempt
- Write down where you are before you start, then track the treatment week by week. The preventive trial tracker is made for this.
- Give each preventive a fair trial: an adequate dose for long enough, usually two to three months, unless side effects stop it sooner.
- Watch the right numbers. With a constant headache, the number of headache days may never change. In the Botox study, only 6.9% had fewer headache days, but 27.6% had less severe pain.42 Fewer severe days, lower usual pain or fewer painkiller days still count.
- Keep a full list of everything tried, with doses and dates, in your headache history.
- Ask about a headache specialist if two or three preventives haven’t helped. Resources has directories.
References
Numbers in the text link to these sources. Where the evidence comes from migraine rather than NDPH, the text says so.
- 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
- 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
- Hughes LS, Clark J, Colclough JA, Dale E, McMillan D. Acceptance and commitment therapy (ACT) for chronic pain: a systematic review and meta-analyses. Clin J Pain 2017;33:552-68. doi.org/10.1097/AJP.0000000000000425
- 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
- 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
- Robbins MS, Grosberg BM, Napchan U, Crystal SC, Lipton RB. Clinical and prognostic subforms of new daily-persistent headache. Neurology 2010;74:1358-64. doi.org/10.1212/WNL.0b013e3181dad5de
- 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
- Cheema S, Lagrata S, Rantell KR, Ahmed M, et al. OnabotulinumtoxinA for primary new daily persistent headache and comparison to chronic migraine. Cephalalgia 2025;45(2):3331024251317448. doi.org/10.1177/03331024251317448
- Ali A, Kriegler J, Tepper S, Vij B. New daily persistent headache and onabotulinumtoxinA therapy. Clin Neuropharmacol 2019;42:1-3. doi.org/10.1097/WNF.0000000000000313
- Cheema S, Rantell KR, Pickering R, Lagrata S, et al. Calcitonin gene-related peptide monoclonal antibody treatment for new daily persistent headache. J Headache Pain 2025;26:170. doi.org/10.1186/s10194-025-02111-2
- Buture A, Tomkins EM, Shukralla A, Troy E, et al. Two-year, real-world erenumab persistence and quality of life data in 82 pooled patients with abrupt onset, unremitting, treatment refractory headache and a migraine phenotype. Cephalalgia 2023;43:3331024231182126. doi.org/10.1177/03331024231182126
- Miller S, Lagrata S, Matharu M. Multiple cranial nerve blocks for the transitional treatment of chronic headaches. Cephalalgia 2019;39:1488-99. doi.org/10.1177/0333102419848121
- Prakash S, Shah ND. Post-infectious new daily persistent headache may respond to intravenous methylprednisolone. J Headache Pain 2010;11:59-66. doi.org/10.1007/s10194-009-0171-x
- Prakash S, Saini S, Rana KR, Mahato P. Refining clinical features and therapeutic options of new daily persistent headache: a retrospective study of 63 patients in India. J Headache Pain 2012;13:477-85. doi.org/10.1007/s10194-012-0461-6
- Pomeroy JL, Marmura MJ, Nahas SJ, Viscusi ER. Ketamine infusions for treatment refractory headache. Headache 2017;57:276-82. doi.org/10.1111/head.13013
- Lagrata S, Cheema S, Watkins L, Matharu M. Long-term outcomes of occipital nerve stimulation for new daily persistent headache with migrainous features. Neuromodulation 2021;24:1093-9. doi.org/10.1111/ner.13282