Treatment response and white matter hyperintensities in 328 patients with new daily persistent headache: A retrospective real-world study

Background and aims: New daily persistent headache (NDPH) is a primary headache disorder characterized by the abrupt onset of continuing and unremitting headache within 24 h of onset. Diagnosis is clinical, requiring exclusion of secondary causes, with limited imaging and treatment data. We assessed the prevalence of nonspecific white matter hyperintensities (WMH) and treatment response in a large retrospective cohort with primary NDPH. Methods: A retrospective chart review was conducted on 328 patients diagnosed with NDPH by a headache subspecialist over an 8.5-year period. Patients were classified into the migraine phenotype (MP; n = 260) or tension-type phenotype (TTP; n = 50) based on associated features. The presence of WMH reported on MRI scans and acute and preventive treatment responses were evaluated. Results: WMH were reported in 20.9% of MP patients (33/158) and 18.0% of TTP patients (9/50), p = .658. Acute treatments for the MP and TTP were minimally, if at all, effective. Preventive treatments generally had limited effectiveness. For the MP, the percentages of patients achieving a 30% or greater reduction in headache days per month were the following: desvenlafaxine, 54.5%; venlafaxine, 41.2%; and onabotulinumtoxinA, 27.9%. Venlafaxine was the most effective for the TTP with 25% having a 30% or greater reduction in headache days. Greater occipital and pericranial nerve blocks were mildly effective while surgical procedures were largely ineffective. Up to five day inpatient intravenous regimens with dihydroergotamine produced temporary benefit in 41.7%. Conclusions: WMH are present in a minority of NDPH patients. Acute treatment is largely not effective. Preventive treatments were more effective in those with MP than TTP with many failures. Future prospective studies with new treatments are needed to identify effective interventions for this often disabling and refractory disorder.