New daily-persistent headache and International Headache Society criteria: A retrospective analysis of 62 patients

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1 ARTIGO ORIGINAL New daily-persistent headache and International Headache Society criteria: A retrospective analysis of 62 patients Novo critério da Sociedade Internacional de Cefaléia para cefaléia persistente e diária desde o início: análise retrospectiva de 62 pacientes Monzillo PH, Baise-Zung C, Nemoto PH, Costa AR Headache ambulatory of Discipline of Neurology of Santa Casa de São Paulo - Brazil Monzillo PH, Baise-Zung C, Nemoto PH, Costa AR. New daily-persistent headache and International Headache Society criteria: A retrospective analysis of 62 patients. Migrâneas cefaléias 2007;10(3):77-81 ABSTRACT Introduction. New Daily-Persistent Headache (NDPH) is described as a type of daily headache that becomes continuous in a short period of time (a maximum of three days). As any newly recognised headache condition, there is a paucity of reports. Therefore, its characteristics in different populations must be further described. Objectives. To describe the characteristics of NDPH in a Brazilian out-patient population. Methods. Sixty-two patients with a diagnosis of New Daily- Persistent Headache (NDPH), out of 1,348 records of outpatients regularly cared for at the Headache Clinic of Irmandade da Santa Casa de São Paulo - Brazil, had their charts reviewed. Results. Clinical characteristics were: female gender 58.1%; whole head pain=72.6%; moderate/strong intensity=93.6% and throbbing quality=43.5%. Of the 62 patients with the diagnosis of NDPH, only 19.4% did not have any clinical improvement when submitted to treatment. Diagnostic exams carried out in 56.5% of the patients contributed very little to the detection of an underlying organic substrate. Conclusion. Our results conflicted with those of the literature and with the IHS 2004 criteria regarding pain intensity, pain quality and the associated phenomena, isolated or in combinations. Perhaps the NDPH IHS 2004 diagnostic criteria should be revised. Key words: Chronic daily headaches; migraine; Chronic Tension-type headache; migraine; New daily-persistent headache; International Headache Society criteria. RESUMO Introdução. Cefaléia persistente e diária desde o início (CPDI) é descrita como um tipo de cefaléia diária que se torna continua em um curto período de tempo (máximo de três dias). Como toda condição recém-reconhecida, ainda há uma pequena quantidade de descrições. Assim sendo, suas características em diferentes populações devem ser descritas. Objetivos. Descrever as características da CPDI em uma população de pacientes brasileiros ambulatoriais. Mé- todos: Foram revisados os prontuários de 62 pacientes com o diagnóstico de CPDI, oriundos de uma população de pacientes do ambulatório de cefaléias da Irmandade da Santa Casa de São Paulo - Brasil. Resultados. As características clínicas foram: gênero feminino=58,1%; cefaléia holocraniana=72,6%; dor moderada a intensa=93,6%, qualidade pulsátil=43,5%. Dos 62 pacientes com o diagnóstico de CPDI, apenas 19,4% não apresentaram melhora ao serem submetidos a tratamento. A investigação complementar, realizada em 56,5% dos pacientes pouco contribuiu para a detecção de um substrato orgânico. Conclusão. Nossos resultados foram discordantes daqueles da literatura dos critérios da IHS de 2004, no que tange a intensidade da dor, sua qualidade e fenômenos concomitantes, isolados ou em combinação. Talvez os critérios diagnósticos da IHS/2004 devam ser revisados. Palavras alavras-chave: Cefaléia crônica diária; migrânea; cefaléia tipo-tensão crônica; cefaléia persistente e diária desde o início; critérios da International Headache Society. Migrâneas cefaléias, v.10, n.3, p.77-81, jul./ago./set

2 PAULO HÉLIO MONZILLO ET AL INTRODUCTION Vanast 2 first described New Daily-Persistent Headache (NDPH) in 1986 as a benign Chronic Daily Headache (CDH). In 1996, Silberstein and cols. 3 suggested diagnostic criteria for this entity as NDPH was not part of the 1988 IHS classification. 4 New daily-persistent headache, according to the International Headache Society (IHS 2004), 1 is described as a type of daily headache that becomes continuous in a short period of time (a maximum of three days). The pain is typically a pressing or tight non-pulsating throb, bilateral and of mild to moderate intensity. Photophobia, phonophobia, nausea and the attack intensity are not aggravated by routine physical exercises. The symptoms must be present for more than three months and not attributable to other causes. Headaches secondary to Cerebral Spinal Fluid (CSF) hypotension, CSF hypertension, post-traumatic headache and headaches secondary to infectious clinical conditions (particularly where infecting agents are present) must always be diagnosed through appropriate investigations when suspected. In compliance with IHS 2004, NDPH can evolve during a period of time in two clinical ways: one autolimited presentation that disappears spontaneously after a few months without treatment and a chronic and normally intractable headache regardless of the therapeutic approach utilized. The IHS closes its comments suggesting that further research studies should be undertaken that better characterize its clinical features and propose possible pathophysiological mechanisms, and conclude definitively the separation from Chronic Tension-Type Headache (CTTH). Few reports are available in the literature involving large NDPH patient samples. 2,5 Its etiology remains unknown, 6 although some authors have tried to imply a temporal relationship to infectious clinical conditions, particularly Epstein-Barr virus (EBV). 7,8 We conducted a retrospective analysis of a large database of headache patients to describe the demographic data and clinical caractheristics of NDPH. PATIENTS AND METHODS We carried out a retrospective analysis consisting of a total of 1,348 records. Of this group, 241 patients presented a headache with a frequency of 15 days or more a month, for at least three months. Sixty-two patients had an NDPH diagnosis in accordance with Silberstein's proposed criteria for new daily persistent headache. 3 Data were recorded regarding the demographic aspects, clinical characteristics of the headache attacks, as well as the presence of accompanied symptoms. More than half the patients were submitted to secondary investigations. Patients with previously diagnosed headache conditions were excluded even if they presented with a clinical picture compatible with NDPH, in order not to include CTTH or CDH bearers. We also recorded the therapeutic recommendations given at the first appointment in our out-patient clinic (abortive or prophylactic) that resulted in clinical improvement, or the treatment scheme substituted when patients did not present any improvement. RESULTS Thirty-six patients (58.1%) were female. The average age at the beginning of the symptoms was of 40.5 years, slightly lower among women (36.7) when compared to men (44.3) (Figure1). Female Male Figure1: Age at the beginning of symptoms The average time delay between initial symptoms and the first appointment at our clinic was 5.9 years. The bilateral localization of the attack occurred in 45 patients (72.6%). Pulsating-type pain was present in 43% of the patients, followed by stabbing pain in 14 (22.6%), pressing in 12 (19.4%), tightening in 4 (6.5%) and burning in 3 (4.8%). Two patients (3.2%) cited different pain types in separate attacks (tightening and pulsating) (Table 1). Strong to moderately intensive attacks were found in equal percentages (46.8%) in our sample, and mild attacks in four patients (6.4%) (Figure 2). Only 11 patients (17.7%) did not refer to any 78 Migrâneas cefaléias, v.10, n.3, p.77-81, jul./ago./set. 2007

3 NEW DAILY-PERSISTENT HEADACHE AND INTERNATIONAL HEADACHE SOCIETY CRITERIA: A RETROSPECTIVE ANALYSIS OF 62 PATIENTS Table 1. Analysis related to pain quality Pain quality N (62) % Pulsating Stabbing Pressing Tightening Burning Tightening + Pulsating Figure 2: Pain Intensity Table 2. Symptoms related to headaches Symptoms N(62) % Pt N Pn + Pt Pn + Pt + N Pn+ Pt+ N+ V N + V Pt + N Pt + Pn + O Pt + N + O Pt + Pn + D N + D Pt + Pn + N + V + O AP D Absence of symptoms Pt: photophobia; N: nausea Pn: phonophobia; V: vomit; O: osmophobia; D: dizziness; AP: autonomic phenomenae; AS: absence of symptoms symptoms associated with their attacks. All other patients presented isolated or associated symptoms that usually accompany migraine attacks. Two patients reported the presence of autonomic symptoms related to their attacks (Table 2). Fifty-five patients (56.5%) were submitted to further investigation. Within this group, it was possible to establish a factor temporally related to the initial symptoms in only three patients. Two patients reported a history of headaches after cranial-cerebral trauma and one patient had headaches following an otomastoiditis infection. Head computed tomography (Head CT-scan) was not useful in detecting abnormalities that justified the clinical symptoms. In the mastodectomized patient, the CT evidenced only a hypoattenuated area in the right temporal region adjacent to the mastoidectomy. In the remaining patients, radiological and laboratorial findings include the following: a venous angioma (right frontal) and a left frontal cavernoma, revealed by Magnetic -Ressonance Imaging (MRI). Onepatient, had a positive serology testfor HIV virus, however without an AIDS-defining clinical picture. Despite the daily frequency and the intensity of the attacks being predominantly moderate to strong, only 28 patients (45.2%) of our sample constantly and abusively used abortive medication on the occasion of their first appointment. Different prophylactic schemes were used, as monotherapy or in different combinations. It is important to point out that the majority of the patients had already used at least one of the prophylactic medicines - at the moment of their first evaluation at our clinic. The list of prophylactic medicines used by those patients during their treatments is illustrated in Table 3. Only ten patients (16.1%) remained totally asymptomatic and twelve patients (19.4%) did not respond to any of the proposed treatments. Twenty-six patients (41.9%) reported a partial improvement of symptoms; in ten of the patients the improvement obtained was related to the attack frequency, in two patients to the attack duration and in 14 patients to the pain intensity. In 14 (22.6%) records it was not possible to obtain data regarding therapeutic efficiency. Table 3. Prophylactic Medication Used Drug Number of patients (%) Amitriptyline 44 (71.0) Flunarizine 19 (30.6) Sodium Valproate 17 (27.4) Propranolol 12 (19.3) Nortriptylin 11 (17.7) Atenolol 06 (9.7) Topiramate 03 (4.8) Clorpromazin 03 (4.8) Carbamazepine 02 (3.2) Prednisone 02 (3.2) Pizotifen 02 (3.2) Oxcarbazepine 01 (1.6) Lithium Carbonate 01 (1.6) Migrâneas cefaléias, v.10, n.3, p.77-81, jul./ago./set

4 PAULO HÉLIO MONZILLO ET AL DISCUSSION Although there are few reports refering to this type of headache in the literature, the NDPH has been a part of the IHS classification since 2004, included in group 4 - Other primary headaches 1. The major characteristic of the NDPH is that the headaches are persistentfrom the onset. Although many patients can't relate the initial symptoms to any cause, a majority are able to pinpoint the start date, even though time has past. Some authors suggest that the initial headache occurs in relation to temporal viral conditions, infections, extracranial surgeries or stressing life events. 6,9,10,11,15 Li and Rozen 6 observed that more than 80% of the patients could recallthe exact date of the initial symptoms and 54% correlated the start of the symptoms to a precipitating event, generally a flu type illness. Other authors go further, linking these infectious conditions to the Influenzae 9 virus or to the Epstein-Baar 7,8 virus with the intention of attributing the NDPH to an infectious etiopathogenesis. This did not occur in any of our cases. There was no (spontaneous) mention suggesting viral infections at the time of the initial symptoms. More than half of the patients (56.5%) of our sample were submitted to imaging and laboratory exams that did little to contribute to the diagnostic elucidation. The rest of the patients did not follow the investigation protocol because they were refered to our clinic many years after the start of symptoms (average of 5.9 years). Only in three patients was it possible to link the start of the symptoms to a putative causal factor. In this analysis, we observed the predominance of female NDPH, as previously shown by the Vanast report and Li and Rozen's. In only one recent research study was it reported that males had a preponderance of NDPH. The IHS diagnostic criteria does not take into consideration the disparity between males and females. 2,6,11 In our study, the average age for the onset of NDPH was 40.5 years, women had their initial headache symptoms earlier than men, and this data is in accordance with the literature. 6 This demographic data is also not mentioned in the IHS criteria. The majority of our patients presented a headache localized bilaterally, which parallels the observations by Li and Rozen, and Takase and cols. They also described the pain bilateral in accordance with the IHS criteria, although this is not obligatory. 6,11,1 Pain referred to as pulsating was reported in 43.5% of our sample. Various authors also consider this as the most common related pain. 5,6,11,12 We call attention to the fact that this conflicts directly with the current IHS 2004 classification that describes the type of pain of NDPH as being pressing or tightening but never pulsating. 1 Nearly half the sample (46.8%) classified the intensity of their attack as being strong but when combined with those who refered to the pain as moderate, the amount increases to 93.5%. Li and Rozen 6,5 had already suggested as one of the diagnostic criteria of NDPH a pain intensity variation between moderate and strong. Therefore, we question the IHS criteria that refers to the pain intensity of the NDPH as being mild, as fluctuations can occur. 1 In contradiction to the IHS 2004 criteria, 82.3% of our patients presented similar migraine attacks as opposed to CTTH, evidenced by the association of pain with: nausea, photophobia and phonophobia, isolated or in different combinations. These three symptoms were the most relevant in our experience. Our results are in total 2,6, 9,12 accordance with the literature. Few reports in the literature make a recommendation regarding the treatment of NDPH. Various therapeutic strategies were used by the patients in our out-patient clinic in monotherapy or in association. We observed clinical improvements in 36 patients (58%) and complete remission of pain symptoms in 10 patients (16.1%). That percentage of partial and complete therapeutic response is significant, considering the degree of the symptoms. Vanast 2 describes that a number of patients can improve with medical therapy treatment, however, he emphasizes that they may have difficulty accessing that treatment. Rozen also reiterates the difficulty to define the best treatment strategy for NDPH, emphasizing that succesful responses occurred in a limited amount of patients with the use of gabapentin and topiramate. 13 CONCLUSION For nearly two decades, publications are available for this intriguing type of headache. Clinical and demographic data involving large series of patients are still lacking, not to mention a total non-acquaintance of the etiopatogenesis of this entity. In this article, we emphasize that the NDPH holds a clinical similarity with migraines but cannot be confused with the CTTC, since the latter is an evolution of the Tension-Type Headache (TTH) according to the IHS 2004 diagnostic criteria. There are relevant conflicts in the clinical aspects observed in our sample research and in the literature, 2,6,9,12 80 Migrâneas cefaléias, v.10, n.3, p.77-81, jul./ago./set. 2007

5 NEW DAILY-PERSISTENT HEADACHE AND INTERNATIONAL HEADACHE SOCIETY CRITERIA: A RETROSPECTIVE ANALYSIS OF 62 PATIENTS when compared with the diagnostic criteria established by IHS 2004 such as: pain intensity, pain quality and the concomitant phenomena present in migraine attacks: nausea, photophobia and phonophobia, in an isolated way or in different combinations. Therefore we suggest that the diagnostic criteria established by IHS 2004 should be revised in the future. Additional clinical characterization and pathophysiological research must be stimulated in order to improve our understanding of this particular entity. REFERENCES 1. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders, 2nd Edition. Cephalalgia. 2004;24(suppl): Vanast WJ. New daily persistent headaches: definition of a benign syndrome. Headache. 1986;26: Silberstein SD; Lipton RB; Sliwinski M. Classification of daily and near-daily headaches: field trial of revised HIS criteria. Neurology. 1996;47: Headache Classification Subcommittee of the International Headache Society. Classification and Diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia. 1988;8(supp7): Rozen TD. New daily persistent headache. Curr Pain Headache Rep. 2003;7: Li D, Rozen TD. The clinical characteristics of new daily persistent headache. Cephalalgia. 2002;22: Diaz-Mitoma F; Vanast WJ; Tyrrel DLJ. Increased frequency of Epstein-Barr virus excretion in patients with new daily persistent headaches. The Lancet. 1987;1: Hamada T, Oshima K, Ide Y, Sakato S, Takamori M. A case of new daily persistent headache with elevated antibodies to Epstein-Barr virus (abstract). Jpn J Med. 1991;30(2):161:3. 9. Evans, RW; Rozen, TD. Etiology and treatment of new daily persistent headache. Headache. 2001;41: Takase Y, Nakano M, Tatsumi C. Primary new daily persistent Headache (NDPH): clinical characteristics of forty-three cases in Japan. Rinsho Shinkeigaku. 2003;43(9): Abstract. 11. Takase Y, Nakano M, Tatsumi C, Matsuyama T. Clinical features, effectiveness of drug-based treatment, and prognosis of new daily persistent headache (NDPH): 30 cases in Japan. Cephalagia. 2004;24: Goadsby, PJ; Boes, C. New daily persistent headache. J Neurol Neurosurg Psychiatry. 2002;72: ii6-ii Rozen TD. Succesful treatment of new daily persistent headache with gabapentin and topiramate. Headache. 2002;42:433. Disclosure: The authors have reported no conflicts of interest Recebido: 29/08/ 2007 Aceito: 31/ Endereço paa correspondência Dr. Paulo H. Monzillo Av. Albert Einstein, 627 room 1306 São Paulo-Brazil Tel-55(11) ; Fax: 55(11) Migrâneas cefaléias, v.10, n.3, p.77-81, jul./ago./set

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