Increased frequency of Epstein-Barr virus excretion in patients with new daily persistent headaches

New daily-persistent headache versus tension-type headache

New daily-persistent headache (NDPH) and chronic tension-type headache (CTTH) are two forms of primary chronic daily headache of long duration that often are similar in their headache manifestations. NDPH distinguishes itself from CTTH and the other forms of chronic daily headache by its continuous head pain from onset. However, despite formalized criteria that specify NDPH must resemble the acute onset of a headache identical to that of CTTH, NDPH commonly has migraine features. Here, we review the available literature on NDPH and compare its clinical features, epidemiology, prognosis, inciting factors, and treatment to CTTH.

New daily persistent headache

New daily persistent headache (NDPH) is a unique form of chronic daily headache (CDH) which is marked by a daily headache from onset, typically occurring in individuals without a significant prior history of headaches. There are two subforms of NDPH: one which is self-limited and normally goes away without therapy, and a more chronic refractory form which is unresponsive to typical headache treatment strategies. The pathogenesis of NDPH is unknown but recent observations suggest a connection with cervical spine hypermobility and elevation of proinflammatory cytokines in the cerebrospinal fluid (CSF). Recognized triggers for NDPH include infection, stressful life events, and surgical procedures. Clinically, NDPH is characterized by continuous head pain of mild to severe intensity. Migrainous symptoms are common. The syndrome appears to affect women in their teens and 20s, while males develop NDPH later in life in their 50s or 60s. There are no recognized treatments for this condition, although treatment options will be discussed. Secondary mimics of NDPH will also be touched upon in this chapter.

Clinical and prognostic subforms of new daily-persistent headache

BACKGROUND

According to the International Classification of Headache Disorders (ICHD)-2, primary daily headaches unremitting from onset are classified as new daily-persistent headache (NDPH) only if migraine features are absent. When migraine features are present, classification is problematic.

METHODS

We developed a revised NDPH definition not excluding migraine features (NDPH-R), and applied it to consecutive patients seen at the Montefiore Headache Center. We divided this group into patients meeting ICHD-2 criteria (NDPH-ICHD) and those with too many migraine features for ICHD-2 (NDPH-mf). We compared clinical and demographic features in these groups, identifying 3 prognostic subgroups: persisting, remitting, and relapsing-remitting. Remitting and relapsing-remitting patients were combined into a nonpersisting group.

RESULTS

Of 71 NDPH-R patients, 31 (43.7%) also met NDPH-ICHD-2 criteria. The NDPH-mf and the NDPH-ICHD-2 groups were similar in most clinical features though the NDPH-mf group was younger, included more women, and had a higher frequency of depression. The groups were similar in the prevalence of allodynia, triptan responsiveness, and prognosis. NDPH-R prognostic subforms were also very similar, although the persisting subform was more likely to be of white race, to have anxiety or depression, and to have a younger onset age.

CONCLUSIONS

Current International Classification of Headache Disorders (ICHD)-2 criteria exclude the majority of patients with primary headache unremitting from onset. The proposed criteria for revised new daily-persistent headache definition not excluding migraine features (NDPH-R) classify these patients into a relatively homogeneous group based on demographics, clinical features, and prognosis. Both new daily-persistent headache with too many migraine features for ICHD-2 and new daily-persistent headache meeting ICHD-2 criteria include patients in equal proportions that fall into the persisting, remitting, and relapsing-remitting subgroups. Our criteria for NDPH-R should be considered for inclusion in ICHD-3.

Post-infectious new daily persistent headache may respond to intravenous methylprednisolone

New daily persistent headache (NDPH) is a subtype of chronic daily headache (CDH) that starts acutely and continues as a daily headache from the onset. It is considered as one of the most treatment refractory of all headache syndromes. The pathophysiology is largely unknown. Viral infections, extracranial surgery, and stressful life events are considered as triggers for the onset of NDPH. A few patients may have the onset of their symptoms during an infection. Here we report nine patients with NDPH like headache. All of them had a history suggestive of extracranial infections a few weeks prior to the onset of headache. All patients received intravenous methyl prednisolone (IV MPS) for 5 days. Intravenous MPS was followed by Oral steroids for 2–3 weeks in six patients. The relief of headache started between the second and fifth days of infusion in all patients. The steady improvement in headache continued and seven patients experienced almost complete improvement within 2 weeks. Two other patients showed complete improvement between 6 and 8 weeks after initiation of IV MPS therapy. We conclude that NDPH-like headache may occur as a post infectious process following a recent infection. We also speculate on the possible mechanisms of headache in our patients.

Focus on therapy: hemicrania continua and new daily persistent headache

Hemicrania continua (HC) and new daily-persistent headache (NDPH) represent the only two forms of chronic daily headache in Chap. IV "Other Primary Headaches" of the second edition of the International Classification of Headache Disorders. HC and NDPH are rare and poorly defined from a pathophysiological point of view; as a consequence, their management is largely empirical. Indeed, there is a lack of prospective, controlled trials in this field, and treatment effectiveness is basically inferred from the results of sparse open-label trials, retrospective case series, clinical experience and expert opinions. In this narrative review we have summarised the information collected from an extensive analysis of the literature on the treatment of HC and NDPH in order to provide the best available and up-to-date evidence for the management of these two rare forms of primary headache. Indomethacin is the mainstay of HC management. The reported effective dose of indomethacin ranges from 50 to 300 mg/day. Gabapentin 600-3,600 mg tid, topiramate 100 mg bid, and celecoxib 200-400 mg represent the most interesting alternative choices in the patients who do not tolerate indomethacin or who have contraindications to its use. NDPH is very difficult to treat and it responds poorly only to first-line options used for migraine or tension-type headache.

Headache attributed to a substance or its withdrawal

Medication overuse, and subsequent medication overuse headache (MOH), is a growing and still underestimated problem worldwide. A significant number of recent epidemiological studies suggest that up to 4% of the general population in Europe, North America, and Asia overuse analgesics and other drugs for the treatment of pain conditions such as migraine. These studies also provide convincing evidence that about 1% of the general population suffers from MOH. The condition can be caused by almost all antiheadache drugs, including analgesics, ergots, triptans, and combined preparations. The clinical symptoms of MOH are heterogeneous and may vary from just an increase in headache attack frequency to a constant holocranial pain over years. The International Headache Society (IHS) defined MOH in its first classification in 1988 but modified the diagnostic criteria in its second classification in 2004 to facilitate diagnosis and the conduct of clinical trials. The underlying pathophysiology of MOH is not well understood. The only therapy is withdrawal from the overused substances. The only strategy to reduce the prevalence of MOH is to prevent the development of MOH in the first place by clear restriction of monthly doses of antiheadache drugs and constant education of both patients and physicians prescribing or recommending antiheadache drugs.

Headache attributed to infections nosography and differential diagnosis

Headache is a very frequent symptom of infection. It has many possible underlying mechanisms, of which two or more can coexist in a single patient. It can be caused by direct stimulation of intracranial pain-producing structures, as in the case of brain abscesses, by irritation of the pachy- and leptomeninges, as in cases of bacterial or viral meningitis, or by a state of intracranial hypertension, as seen in obstructive hydrocephalus. There is no doubt that headache is often the first or the predominant symptom of serious, sometimes life-threatening, infectious diseases; certainly, it is a condition frequently encountered in all epidemiological studies. Indeed, it is estimated that over 60% of people have, at some point in their lives, experienced headache during an infection. This evidence leads to the need for a systematic approach to headache secondary to infection. This chapter provides some elements on pain mechanisms in systemic and intracranial infections and on the possible role of antimicrobial agents in the genesis of headache. The first section provides a detailed "etiology-based" description of the International Classification of Headache Disorders, 2nd edition (ICHD-II: Headache Classification Subcommittee of the International Headache Society, 2004), while the second section presents a "symptom-based" algorithm applicable in the first diagnostic assessment, according to the headache features and to the most frequently associated clinical manifestations during infections of the central nervous system (CNS).

New daily persistent headache in children and adults

New daily persistent headache (NDPH) is frequently seen in young patients with chronic daily headache. NDPH begins with a sudden onset, often associated with an infection or other physical stress. This headache syndrome is difficult to treat and may persist for years. This review discusses the epidemiology, comorbid symptoms, evaluation, and treatment of this disorder.

Meningismus is a commonly overlooked finding in tension-type headache in children and adolescents

At present, both migraine and tension-type headaches in children are believed to be chronic primary headaches. Meningeal signs in both cases are ignored or not examined, and the neurologic status is considered normal. This is the first study that focuses on meningeal signs in children with chronic headaches. The study population comprised 1738 patients aged 5 to 17 years who were examined in an outpatient neurologic clinic over a 6-year period. Particular attention was paid to examination of meningeal signs, including nuchal rigidity, Kernig's sign, Brudzinski's three signs (upper, middle, and lower), the "tripod" sign, and Guillain's and facial signs; the presence of these signs was regarded as meningismus syndrome. Some meningeal signs were found in 12% of 1007 children suffering from migraine, whereas 97% of 731 children with tension-type headaches had the whole set of meningeal signs. This suggested that meningismus is the major clinical syndrome in chronic tension-type headaches in children and adolescents. Chronic mild sterile (possibly autoimmune) inflammation of meninges (dura mater) can be caused by a preceding infection, as well as minor trauma of the head and/or back. Prolonged rest in a recumbent position usually resulted in relief or complete disappearance of both headache and meningeal signs. Monitoring of the meningeal signs is helpful for evaluation of the patient's condition in the course of treatment.

Medication-overuse headache: a worldwide problem

Medication overuse and subsequent medication-overuse headache (MOH) is a growing problem worldwide. Epidemiological data suggest that up to 4% of the population overuse analgesics and other drugs for the treatment of pain conditions such as migraine and that about 1% of the general population in Europe, North America, and Asia have MOH. Recent clinical studies gave further insights in clinical and pharmacological features, such as critical monthly doses and frequencies. These features seem to vary significantly and depend on the primary headache disorder and the type of drug that is overused. Along with these findings the new international classification of headache disorders has now incorporated additional criteria and new headache entities that will facilitate the diagnosis of MOH. Withdrawal therapy is the only treatment for this disorder and clear restriction of monthly doses is the central requirement for successful prevention.

New daily persistent headache

New daily persistent headache (NDPH), which is the acute onset of headache within 3 days and is persistent for 15 days or more each month for at least 3 months, is a predominantly female heterogeneous subtype of chronic daily headache, typically with migraine features of unknown etiology. NDPH may be a presentation of other primary headaches such as new onset migraine, tension, or benign thunderclap headache. The headaches can be difficult to treat. The diagnosis is one of excluding the many secondary types or NDPH mimics, which is especially critical early in the course of the disease when a secondary etiology is more likely. NDPH mimics include postmeningitis headache, NDPH with medication rebound, neoplasms, temporal arteritis, chronic meningitis, chronic subdural hematoma, post-traumatic headaches, sphenoid sinusitis, hypertension, subarachnoid hemorrhage, low cerebrospinal fluid pressure syndrome, cervical artery dissections, pseudotumor cerebri without papilledema, and cerebral venous thrombosis.

New daily persistent headache

New daily persistent headache was first described by Vanast in 1986 as a benign form of chronic daily headache that improved without therapy. In the headache specialist's office, new daily persistent headache is anything but benign and is thought to be one of the most treatment refractory of all headache conditions. Little is known about this syndrome. It is unique in that the headache begins daily from onset, typically in a patient without a history of headache, and can continue for years without any sign of alleviation despite aggressive treatment. This article discusses the epidemiology, diagnostic criteria, clinical characteristics, and treatment strategies for new daily persistent headache.

Imaging chronic daily headache

New imaging technology allows us to study neurologic disorders that have had no previous structural basis. There have been recent reports on the involvement of nociceptive pathways in daily headache. A systematic review was performed using key words "chronic daily headache" and "imaging." This paper reviews the literature on imaging studies performed on daily headache with emphasis on the new imaging technology.

Risk factors for chronic daily headache

There are many people who experience headaches that are independent of illness, injury, or hangover. Approximately 4% of the population suffer from headaches on a daily or near-daily basis. It is apparent that patients with chronic daily headache in community samples differ in important ways from patients with chronic daily headache in subspecialty clinics. In this manuscript, we review clinic-based data on risk factors for chronic daily headache and summarize the current data on the epidemiology of chronic daily headache.

Chronic daily headache: nosology and pathophysiology

Systematic scientific classification of primary headaches is inexact, relying on clinical features because the disorders lack diagnostic markers, although the International Headache Society classification has been successful in providing relatively homogenous clinical groups for pathophysiological and therapeutic studies. One area in which there have been particular difficulties and uncertainty is in classifying patients with frequent headache, particularly chronic daily headache. Clinical research on the topic is limited, and imprecise because of uncertainties of definition. Rigorous basic or applied clinical research is a rarity, attested to by a paucity of new publications in the past year. Accordingly, the scientific basis of chronic daily headaches remains to be determined. There is agreement on one issue: for headache specialists and neurologists this is an important clinical problem. We take the position that chronic daily headache is what it says--frequent headache. As hematologists make a diagnosis of anemia, which invites further investigation and sub-classification, neurologists might diagnose chronic daily headache not to imply that all its causes are the same but simply to begin the clinical process.

The clinical characteristics of new daily persistent headache

New daily persistent headache (NDPH) is a subtype of chronic daily headache. The literature on NDPH is scant and its true aetiology is unknown. A retrospective chart review was carried out from a computerized database at the Jefferson Headache Centre from August 1997 to May 2000 to identify patients with NDPH using the Silberstein et al. criteria. Forty women and 16 men were identified. Age of onset ranged from 12 to 78 years. The peak age of onset was the second and third decade in women and the fifth decade in men. Eighty-two per cent of patients were able to pinpoint the exact day their headache started. Onset occurred in relation to an infection or flu-like illness in 30%. A prior headache history was found in 38% of patients. A family history of headache was documented in 29%. The duration of daily headache ranged from 1.5 h to 24 h; 79% were continuous. Nausea occurred in 68% of patients, photophobia in 66%, phonophobia in 61%, and lightheadedness in 55%. Laboratory testing and neuroimaging in all patients was normal except for Epstein-Barr virus antibody titres, which were positive in 71% of seven patients tested, representing past infection. NDPH appears to be a female-predominant disorder, marked by a continuous daily headache with associated migrainous symptoms. Over 80% of patients could state the exact date their headache began. One-third of patients developed NDPH with a flu-like illness.

Human herpesviruses and neurological disorders of childhood

The human herpesviruses, a group of DNA viruses that includes herpes simplex viruses types 1 and 2, varicella zoster virus, cytomegalovirus, Epstein-Barr virus, and human herpes viruses types 6, 7, and 8, cause substantial neurological morbidity among infants and children. This review describes the biology of these viruses and summarizes the clinical manifestations and therapy of the diseases that result from childhood infection with these important pathogens.

Headache associated with non-cephalic infections: classification and mechanisms

A classification of headache associated with non-cephalic infections is proposed. The classification is supported by published case series and reports. The head pain can be explained by direct activation of pain producing mechanism by microorganisms or can be secondary to fever or to a combination of both.

Chronic infectious mononucleosis; a case report

A 39-year-old woman had an adenitis colli followed by anaemia, splenomegaly, atypical lymphoid cells in blood with increased B-lymphocytes, reduced T-suppressor/cytotoxic cells, increased polyclonal IgM, high titres of EB VCA IgG, EB EA IgD&R +/- and EBNA IgG-. The disease progressed slowly for 2 years, splenectomy was followed by clinical improvement; spleen morphology was compatible with a benign disease of viral origin.

Naloxone-reversible monocyte dysfunction in patients with chronic fatigue syndrome

We studied monocyte function in 35 consecutive patients with chronic fatigue syndrome (CFS) and 25 healthy controls. Eighty-five per cent of the patients showed monocyte dysfunction characterized by marked reduction in the number of monocytes displaying immunoreactive cytoskeletal vimentin filaments, a low phagocytosis index, and a reduced expression of HLA-DR antigens. These values increased dramatically after incubation of the patients' monocytes with the opioid antagonist naloxone. Other immunological abnormalities also noted in the patients were low lymphocyte blastogenesis and diminished numbers of monocytes displaying receptors for Fc of IgG (FcR) and C3b (CR1). These findings suggest that an increased opioid activity acting through a classical receptor mechanism is active on monocytes from a high proportion of patients with CFS and that this represents a novel example of immunomodulation by opioid peptides in human disease. We suggest that endogenous opioids are involved in the pathogenesis of the chronic fatigue syndrome.

Epstein-Barr virus as a cause of autoimmune disease and other medical morbidity in patients with affective disorders

We hypothesize that psychiatric patients suffering from the major affective disorders (depression and manic-depressive illness) may commonly also suffer from a chronic active infection with the Epstein-Barr virus. This infection would be a consequence of the immune dysfunction known to be associated with these disorders of mood. According to this hypothesis, the increased medical morbidity and mortality reported in these psychiatric patients would be attributable in part to diseases in which Epstein-Barr virus is implicated or suspected as a cause.