Abstract
At present new daily persistent headache is just a group of conditions that are connected based on the temporal profile of their mode of onset. If new daily persistent headache is a true distinct syndrome like migraine then we need to start to define subtypes that have specific effective treatments such has been noted for migraine sub-forms. We present what we believe is the first recognized subtype of new daily persistent headache that which starts with a thunderclap headache onset. A patient presented with a 13 month history of a daily headache from onset which initiated as a thunderclap headache along with persistent acalculia. All neuroimaging studies for secondary causes were negative. Nimodipine rapidly and completely alleviated her headache and associated neurologic symptoms. We propose that this subtype of new daily persistent headache is caused by a very rapid increase in CSF tumor necrosis factor alpha levels leading to cerebral artery vasospasm with a subsequent thunderclap headache, then continuous or near continuous cerebral artery vasospasm leading to a persistent daily headache. Nimodipine which not only inhibits cerebral artery vasospasm but also tumor necrosis factor alpha production appears to be a specific treatment for this distinct subtype of new daily persistent headache.
Highlights
The lack of consensus on a clear definition of new daily persistent headache (NDPH) and the fact that we are still searching for adequate therapy reflects on how little we know about this syndrome [1]
Is NDPH a group of conditions that just happen to all start daily from onset and have little else in common including no shared underlying pathogenesis or is there some distinct cortical change that causes a daily headache from onset in all patients with NDPH the mechanism by which this cortical phenomena is triggered may be different for individual patients? If NDPH is a distinct all-encompassing syndrome like migraine we need to define sub-forms that may have specific effective treatments such has been noted for migraine with aura for example [2]
No ischemia was noted on this patient’s brain MRI but that does not mean that one or more of these cortical regions was not altered from persistent oligemia; it just means that changes could not be seen by conventional neuroimaging
Summary
The lack of consensus on a clear definition of new daily persistent headache (NDPH) and the fact that we are still searching for adequate therapy reflects on how little we know about this syndrome [1]. It is possible our patient was an outlier case of prolonged RCVS and the result of persistent cerebral artery vasospasm that lasted for more than one year’s duration, which was not picked up on CT angiography, did not cause ischemia on MRI, but did cause enough oligemia leading to acalculia and head pain and nimodipine alleviated the vasospasm and headache and neurologic symptoms; but this can only be hypothesized.
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