New daily persistent headache is a diagnosis seen frequently at headache centers. These are patients with no previous history of headache who recall a particular day when they developed a headache which has never improved. They are usually seen several months later after they have had normal neuroimaging and been treated with analgesics. In a younger age group, specifically teens and early 20s, the cause is presumed to be a viral illness though this is usually not confirmed. Most of these patients improve gradually, but a few do not, and they are the bane of headache clinics.
New daily headache may also occur in elderly patients. According to Dr Jerry Swanson, in a presentation at the Headache Cooperative of the Pacific Winter Conference, a significant number of these patients may have giant cell / temporal arteritis. This can occur in up to 1% of women and 0.5% of men, usually over the age of 70 and never under the age of 50. Twenty percent will have permanent visual loss. Most have symptoms of diffuse achiness termed polymyalgia rheumatica, and some have jaw claudication, meaning pain in the jaws with chewing, and that symptom is very specific. Three-quarters present with headache as the only symptom.
Four percent of patients have a normal sedimentation rate, and about 9% have a negative temporal artery biopsy.
Several recent studies suggest that low-grade infiltration with the varicella zoster virus, that causes shingles, in the temporal arteries is in fact the cause of this disorder. They recommend using antiviral medications such as Zostrix, Valtrex, Famvir, when the diagnosis is made, with those drugs added to standard therapies.
These therapies are mainly corticosteroids, such as prednisone. They may be needed long-term, i.e., several years, and there are unavoidable adverse effects. Methotrexate or azathioprine is often used for their “steroid-sparing” effects.
Several studies have reported that tocilizumab, a monoclonal antibody, may be effective in patients who are unable to taper steroids to an acceptable, very low level, usually 10 mg or less, or who have intractable disease. One study utilizing that medication was published in the March 4th issue of Lancet.
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