Two Cases of New Daily Persistent Headache Successfully Treated with Onabotulinum Toxin Type A (BoNT-A)

Abstract

This report describes two typical cases of New Daily Persistent Headache (NDPH), refractory to different therapies, who presented a satisfactory response to repeated cycles of Onabotulinum Neurotoxin type A (BoNT-A), (Botox™). NDPH is a primary headache disorder, characterized by continuous and unremitting daily headache with abrupt onset (clearly remembered by the patient) and more than three months in duration. It lacks typical clinical features, being similar to chronic migraine without aura or tension-type headache. It may be self-limiting within months or years without therapy, or be refractory to most treatments. Case N. 1: A 19 year-old woman, without prior headache history, had been suffering for eight months before the first observation from a daily, continuous and unremitting bilateral headache, with features of tension-type headache. She was submitted to various examinations and finally diagnosed as NDPH. Her pain was unresponsive to multiple pharmacological and non-pharmacological treatments. After three cycles of BoNT-A (195 U) she experienced a satisfactory relief of pain and good improvement of her quality of life (QoL). Case N. 2: A 56-year-old woman suffered since eleven years from a daily and continuous headache, pressing/tightening in quality and of moderate intensity, but with daily paroxysms of stabbing pain, without autonomic symptoms. No trigger factors of pain were detected. She experienced a remission period of three years, after that the pain relapsed with the same features. Neurological examination was negative, apart from minimal dysarthria. She was submitted to various examinations (including a complete psychiatric evaluation) and finally diagnosed as NDPH. Her pain was unresponsive to multiple pharmacological treatments. After a week from first cycle of BoNT-A (195 U) she experienced a satisfactory relief of pain and good improvement of her quality of life. Her pain relapsed shortly before subsequent administration of BoNT-A and after a missed cycle: a good relief and substantial improvement of her QoL were finally obtained with further cycles of the treatment. These two cases of NDPH were successfully treated with BoNT-A. We propose this treatment for refractory cases of chronic daily headaches, including NDPH.