Prevalence of new daily persistent headache in the general population. The Akershus study of chronic headachecha_

doi:10.1111/j.1468-2982.2009.01842.x Prevalence of new daily persistent headache in the general population. The Akershus study of chronic headachecha_1842 1149..1155 RB Grande 1,2, K Aaseth 1,3, C Lundqvist 1,4,5 & MB Russell 1,3 1 Head and Neck Research Group and 4 Helse Øst Health Services, Research Centre, Akershus University Hospital, Lørenskog, 2 Faculty Division Ullevaal University Hospital, University of Oslo, 3 Faculty Division Akershus University Hospital, University of Oslo, and 5 Department of Neurology, Ullevaal University Hospital, Oslo, Norway 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 1155. London. ISSN 0333-1024 The aim of the present study was to investigate the prevalence of new daily persistent headache (NDPH) in the general population, and compare the clinical characteristics of NDPH and chronic tension-type headache (CTTH). This is a population-based cross-sectional study. A random sample of 30 000 persons aged 30 44 years was drawn from the population of Akershus County, Norway. A postal questionnaire was screened for chronic headache. Those (n = 633) with self-reported chronic headache within the last month and/or year were invited to an interview and examination by a neurological resident. A follow-up interview was conducted after 1.5 3 years. The headaches were diagnosed according to the International Classification of Headache Disorders, 2nd edn and relevant revisions. The response rate of the questionnaire was 71% and the participation rate of the interview was 74%. Four persons, three men and one woman, had NDPH. The overall 1-year prevalence of NDPH was 0.03%. The clinical characteristics of NDPH and CTTH were similar, except for the sudden onset in NDPH. Three of the four persons with NDPH had. Follow-up disclosed that the symptomatology of NDPH is not unchangeable, since two persons had improvement of their NDPH. NDPH is rare and occurs in one of 3500 persons from the general population of 30 44-year-olds. It is often associated with. New daily persistent headache, epidemiology, chronic headache, prevalence, Ragnhild Berling Grande MD, Head and Neck Research Group, Research Centre Akershus University Hospital, Lørenskog 1478, Norway. Tel. + 47-6798-4405, fax + 47-6792-9469, e-mail r.b.grande@medisin.uio.no Received 29 September 2008, accepted 29 December 2008 Introduction New daily persistent headache (NDPH) was first described in 1986 (1). Diagnostic criteria were proposed some years later, but today the criteria of the International Classification of Headache Disorders, 2nd edn (ICHD-II) are widely accepted (2). The two primary headache entities NDPH and chronic tension-type headache (CTTH) are defined by similar diagnostic criteria (2). The only difference is the sudden onset of NDPH, which is a daily unremitting headache from onset or within 3 days from onset, whereas CTTH often evolves after years with headache and is not necessarily daily. The knowledge of NDPH is sparse, and information is mostly derived from tertiary clinic-based populations (3 6). The classification subcommittee on NDPH has expressed the need for more studies on further clinical characterization and pathophysiological research on this primary chronic headache type, especially studies comparing NDPH with CTTH (2). The objective of this study was to investigate the epidemiology of NDPH and compare its clinical features with CTTH in a population-based sample. 1149

1150 RB Grande et al. Methods Design and participants This study was an epidemiological, cross-sectional study based on a random sample of 30 000 persons, aged 30 44 years from the general population, with equal numbers of each gender. Data from Statistics Norway show that the sampling area was representative of the total Norwegian population regarding age, sex and marital status (7). Regarding employment, trade, hotel/restaurant and transport were over-represented, whereas industry, oil and gas and financial services were under-represented in the sampling area compared with the total Norwegian population. The postal headache questionnaire had a response rate of 71%. Of the 935 persons (267 men and 668 women) with self-reported chronic headache ( 15 days last month and/or 180 days last year), 633 participated in the physician-conducted headache interview and physical and neurological examination. No supplementary investigations such as computed tomography (CT), magnetic resonance imaging (MRI) or spinal puncture, etc. were performed. The participation rate of the interview was 74%. A follow-up interview by phone was conducted 1.5 3 years later. More details have been published elsewhere (8, 9). The Severity of Dependence Scale (SDS) was used to assess dependence characteristics (10). The five items were asked during the interview and the maximum sum score was 15. The questions were related to the intake of headache pain killers last month. Classification The headaches were classified according to the diagnostic criteria of ICHD-II. Another set of diagnostic criteria of NDPH, proposed in 1994, also exist (11). These initial criteria are quite similar to the subsequent ICHD-II criteria, but one notable difference is the lower headache frequency required for diagnosis. In the present study the terminology initial criteria vs. ICHD-II criteria will be used. The initial criteria require a constant headache location and an average headache frequency of 15 days/month for > 1 month, whereas in the ICHD-II criteria, a daily headache for 3 months is required and a constant location is not needed. Another difference is the subdivision of NDPH depending on presence of in the initial criteria, whereas ICHD-II does not include this feature. In the comments to the ICDH-II criteria it is suggested that NDPH can be subdivided into a self-limiting and a refractory subform. Table 1 shows the ICHD-II diagnostic criteria of NDPH and CTTH. The diagnosis of NDPH requires that the onset is clearly recalled. Since both NDPH and CTTH are primary headaches, secondary causes should be ruled out. Headache attributed to chronic rhinosinusitis was defined according to the criteria established by the American Academy of Otolaryngology Head and Neck Surgery (12). Medication was defined to be the level of intake required for the diagnosis of headache (MOH) (2, 13 15) Statistics Statistical analyses were performed using SPSS 14.0.2 for Windows (SPSS Inc., Chicago, IL, USA). Adjusted prevalence rates were calculated using the Vassar College statistics web page and adjusted to the number of responders to the questionnaire, 20 598 persons (9475 men and 11 123 women), since all 935 persons with self-reported chronic headache in the questionnaire had a similar pattern of answers (16). Mean SDS scores of CTTH with and without are presented with 95% confidence intervals (CI), although CIs are not given for the two groups of NDPH, since n < 5. Ethics All participants gave informed consent. The Regional Committee for Medical Research Ethics and the Norwegian Social Science Data Services approved the study. Results Prevalence Three men and one woman had NDPH. This corresponds to an overall 1-year prevalence of NDPH of 0.03% (4/20 598 935/633 100), i.e. 0.06% (3/9475 267/147 100) in men and 0.02% (1/11 123 668/448 100) in women. Clinical characteristics Table 2 shows the clinical characteristics of the four persons with NDPH. All could clearly recall the exact day of headache onset and none of them had a prior history of much headache. They all reported having experienced headache of tension-type sometimes, thus fitting into the diagnosis of infrequent episodic tension-type headache. One man had onset

Prevalence of NDPH in the general population 1151 Table 1 The International Classification of Headache Disorders (ICHD-II) criteria for new daily persistent headache and chronic tension-type headache New daily persistent headache A. Headache for > 3 months fulfilling criteria B D B. Headache is daily and unremitting from onset or from < 3 days from onset C. At least two of the following pain characteristics: 1. Bilateral location 2. Pressing/tightening (non-pulsating) quality 3. Mild or moderate intensity 4. Not aggravated by routine physical activity such as walking or climbing stairs D. Both of the following: 1. No more than one of photophobia, phonophobia or mild nausea 2. Neither moderate or severe nausea nor vomiting E. Not attributed to another disorder Chronic tension-type headache A. Headache occurring on = 15 days/month on average for > 3 months (= 180 days per year) and fulfilling criteria B D B. Headache lasts hours or may be continuous C. Headache has at least two of the following characteristics: 1. Bilateral location 2. Pressing/tightening (non-pulsating) quality 3. Mild or moderate intensity 4. Not aggravated by routine physical activity such as walking or climbing stairs D. Both of the following: 1. No nausea or vomiting (anorexia may occur) 2. No more than one of photophobia or phonophobia E. Not attributed to another disorder Table 2 Clinical characteristics of new daily persistent headache (NDPH) Case 1 Case 2 Case 3 Case 4 Gender Age (years) 41 38 31 37 Age at onset of NDPH (years) 21 37 29 36 Medication + + -* + Age at onset of 26 37 36 (years) Years of at time of examination (years) 15 1 1 Headache (mean doses per day) Ibuprofen (600 mg) Ibuprofen (400 mg) and paracetamol (1000 mg) Ibuprofen (400 mg) Headache (days/month) 30 30 and 30 15 30 and 30 Headache characteristics Bilateral location + - + + Pressing/tightening quality + + + + Mild or moderate intensity + - - + Not aggravated by routine + + + + physical activity Accompanying symptoms Photophobia - + - - Phonophobia - - - - Mild nausea - - - + Paracetamol (1000 mg) and tramadol (200 mg) *At time of diagnosis this man had d analgesics for only 2 months [3 months are required for a diagnosis of - headache according to the ICHD-II (2)].

1152 RB Grande et al. of NDPH at the age of 21 years, i.e. 20 years prior to this study. The remaining three persons had onset of NDPH 1 or 2 years prior to the study. Two men reported severe headache intensity, whereas the other two experienced mild to moderate headache. Accompanying symptoms were few. One man also fulfilled the criteria for headache attributed to chronic rhinosinusitis, due to headache, fatigue and nasal obstruction for > 12 weeks. By anterior rhinoscopy he had localized nasal oedema. He had previously had surgery of the nasal septum. Medication Three of the four persons with NDPH had (Table 2). The fourth person had for 2 months, i.e. 1 month less than required for the diagnosis of MOH. Follow-up Three of the four persons could be followed up. Two were followed up after 1.5 years and one after 3 years. One had unchanged headache symptoms. One had less severe headache intensity after discontinuation of pain killers and 10 mg amitriptyline daily for 12 months prior to follow-up. The woman with NDPH had reduced headache frequency, but otherwise unchanged headache characteristics. Thus, her diagnosis changed from NDPH to CTTH with, i.e. use of ibuprofen and diclofenac for 15 days per month. Six weeks before follow-up, she had cervical prolapse surgery, and her headache improved from this point on. NDPH vs. CTTH Table 3 shows that the clinical characteristics of NDPH and CTTH were similar. The headache was usually a mild-to-moderate, pressing/tightening, bilateral headache that was not aggravated by routine physical activity, i.e. tension-type headache. Nausea was the most common accompanying symptom, followed by photophobia in CTTH, while one person with NDPH experienced mild nausea and another experienced photophobia. Phonophobia was rare in CTTH and not present in the four persons with NDPH. Severity of Dependence Scale score The SDS scores of those with NDPH and CTTH with were high compared with those with NDPH and CTTH without, i.e. 7.33 and 5.61 (5.29 5.93) vs. 4 and 2.73 (2.41 3.05), respectively. Discussion Our main finding was the 0.03% 1-year prevalence of NDPH in the age groups of 30 44 years. The clinical characteristics of our four persons with NDPH were similar to those of CTTH. Medication is common in NDPH, as it is in other forms of chronic headache in the general population (8, 9). Mainly simple analgesics were d. The large population-based sample, the high questionnaire response rate and the high interview participation rate provide data that are representative of the general population. The age group was chosen because chronic headache is prevalent and comorbidity with other disorders less prevalent than in older age groups. In a cross-sectional study the persons are seen only once. Thus, the headache diagnoses are based on one visit. The ruling out of secondary causes in this study was based on the thorough history, the clinical and neurological examination and on no supplementary Table 3 Comparison of new daily persistent headache (NDPH) and chronic tension-type headache (CTTH) characteristics NDPH without (N = 1) NDPH with (N = 3) CTTH without (N = 216) CTTH with (N = 170) Bilateral location of pain 1 2 (66.7%) 204 (94.4%) 152 (89.4%) Pressing/tightening quality 1 3 (100%) 210 (97.2%) 170 (100%) Mild/moderate intensity 0 2 (66.7%) 215 (99.5%) 168 (98.8%) Not aggravated by routine physical activity 1 3 (100%) 213 (98.6%) 169 (99.4%) Photophobia 0 1 (33.3%) 15 (6.9%) 9 (5.3%) Phonophobia 0 0 (0%) 1 (0.5%) 3 (1.8%) Nausea 0 1 (33.3%) 28 (13%) 26 (15.3%)

Prevalence of NDPH in the general population 1153 Table 4 Studies on new daily persistent headache (NDPH) Study Sample source Sample size n (response rate) Diagnostic criteria Cases with NDPH n Prevalence % Norway (present study) (9) General population 30 000 (74%) ICHD-II (3) 4 0.03 Spain (7) General population 2 252 (84%) Initial criteria (2) 2 0.1 Canada (1) Clinic? 45 USA (4) Clinic Initial criteria (2) 56 USA (5) Clinic Initial criteria (2) 69 Japan (6) Clinic ICHD-II (3) 30 ICHD-II, International Classification of Headache Disorders, 2nd edn. investigations such as CT, MRI or spinal puncture, etc. None of the participants had symptoms, signs or clinical findings that suggested a secondary cause of the headache. The ICHD-II mentions some secondary headache diagnoses that may imitate NDPH, i.e. low cerebrospinal fluid (CSF) volume headache, raised CSF pressure headache, posttraumatic headache and headache attributed to infection. Our headache interview could with reasonable certainty rule out the latter two causes, but we could not exclude a CSF-related secondary cause, since we did not perform spinal puncture. One person had symptoms compatible with headache attributed to chronic rhinosinusitis. Some of these symptoms can also be related to headache, i.e. headache and fatigue, but nasal obstruction cannot be entirely excluded as a cause of daily headache. The challenge with possible secondary causes is present in all cross-sectional studies, since a primary headache diagnosis always needs the ruling out of a secondary cause. Clinic studies, on the other hand, are often cohort studies and have the possibility of ruling out secondary causes, but are based on selected populations and therefore not suitable for providing epidemiological data from the general population. NDPH is rare, and for that reason cross-sectional epidemiological surveys and studies of clinic populations supplement each other in order to provide a more complete picture of NDPH. Cross-sectional studies are subject to recall bias. However, the four persons with NDPH in this study all clearly remembered the day on which their headache started and from which point on the headache was daily. However, we cannot completely exclude the presence of inaccurate recall of their headache history. Their previous headache history was sparse and similar to about 90% of the general population, as they had experienced only rare tension-type headache. Table 4 shows previously published population-based and clinic-based studies on NDPH. The prevalence of NDPH was 0.1% in Spain (6). This is three times higher than our findings. We used the more restrictive ICHD-II classification, whereas the Spanish study applied the more inclusive initial criteria, one difference being the lower headache frequency required for diagnosis. The headache does not need to be daily for a diagnosis of NDPH in the Spanish study, in contrast to the ICHD-II criteria, which require a headache every day for 3 months (2). Thus, the use of different diagnostic criteria may explain the discrepancy. However, both the Spanish and our study encountered few persons with NDPH, suggesting that NDPH is rare. An American study of 56 patients with NDPH from a tertiary headache clinic found a female preponderance and migraine symptomatology to be common when applying the initial criteria (3). These findings do not match our results. The main reasons are probably the use of different diagnostic criteria and different populations, i.e. clinic population vs. general population. More specifically, the criteria used may explain the female predominance, since they include persons with the same headache frequency as in the ICHD-II diagnostic criteria for CTTH. Had the American study used the ICHD-II criteria, it is likely that some NDPH cases would have been classified as CTTH. We know from other studies that CTTH has a female predominance (8). This American study found a peak age of onset in the second and third decades in women and fifth decade in men in a clinical population. Our prevalence of NDPH among 30 44-year-olds from the general population may represent a slight underestimation compared with the prevalence in the whole adult population. Another American study from a tertiary headache centre also used the initial proposed criteria for NDPH on 638 patients with chronic headache (4). They found that the most common diagnosis was chronic migraine (87.4%), followed by NDPH (10.8%) and CTTH (0.9%). This is in contrast to our population-based survey, where

1154 RB Grande et al. CTTH is by far the most common type of chronic headache, whereas chronic migraine and NDPH are rare. Again, use of different diagnostic criteria and different populations are likely to explain the differences. Only those with severe and complex headache are referred to tertiary specialist centres. A Japanese clinic-based study on 30 patients with NDPH defined according to the ICHD-II criteria found that NDPH and CTTH were similar, just as we did (5). They found nausea to be the most common accompanying symptom and present in 33% of the sample. The ICHD-II suggests in the comments to the classification that NDPH may be subclassified into a self-limiting subform that resolves within months, and a refractory subform that is resistant to aggressive treatment. At time of diagnosis all our cases had an NDPH history for longer than a year, and could therefore not receive the diagnosis of the self-limiting subform. They had all tried different s, but still had daily headache. The treatment, however, cannot be characterized as aggressive, since it consisted of self-administered overthe-counter analgesics. Thus, our four cases do not fit into either of the two subforms. Adding the follow-up data in order to attempt a subclassification of NDPH, we still found that the case without improvement on simple analgesics cannot be subclassified. The man with headache improvement had taken amitriptyline for 1 year, and his improvement could represent either a spontaneous improvement after 1.5 years or a response to prophylactic, neither of which ia helpful with respect to an NDPH subclassification. For the above reasons, the suggested subforms of selflimiting NDPH and treatment-refractory NDPH may not be very useful concepts in practice, and it is indeed impossible to comply completely with the suggested criteria regarding these entities. According to the ICHD-II criteria, the improvement of the woman changed her diagnosis from NDPH to CTTH. Therefore, how to deal with an improvement of NDPH is not clear in the classification. There have been suggestions of representing a type of dependence (17, 18). Our finding of a high SDS score fits with our previous findings of high SDS scores in other primary chronic headaches where is often seen. In the present four persons with NDPH, it would seem that the headache itself is the reason for the rather than vice versa. However, it is unclear why is continued despite often very little effect. Furthermore, it is not clear to what extent the headache characteristics of the described persons are influenced by their. There is a challenge in the ICHD-II classification with regard to NDPH and of. In this case series, was present in three out of four persons. All were certain about having developed after and because of their chronic headache. This is also supported by the lack of a former headache history. It is emphasized in the classification that the lack of a former headache history is typical. When this is the case it is impossible to code for any pre-existing headache. The only option left is to code for both NDPH and MOH. We found that of may often be present in NDPH and therefore, in agreement with the authors of the initial criteria, suggest that the ICHD opens for a subclassification of NDPH into subtypes with and without. For the diagnosis of MOH among NDPH patients, however, it is difficult to apply the criterion saying that headache has developed or markedly worsened during. Further descriptive studies of the subtypes of NDPH and -withdrawal studies could then in the future help to clarify whether contributes to the maintenance of NDPH or is simply a consequence of attempting to manage a chronic headache. References 1 Vanast WJ. New daily persistent headaches: definition of a benign syndrome. 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