New daily persistent headache: A lack of an association with white matter abnormalities on neuroimaging

Objective To provide results from the largest study of new daily persistent headache patients to date and specifically evaluate if patients with primary new daily persistent headache develop white matter abnormalities or infarct-like lesions on neuroimaging. Methods Retrospective analysis of patient medical records utilizing an electronic medical record system. All patients were seen at a headache specialty clinic by a single headache neurologist and diagnosed with primary new daily persistent headache during the time period of January 2009 to January 2013. Results Altogether, 97 patients were diagnosed with primary new daily persistent headache (65 women and 32 men). The mean average age of onset was slightly younger in women than men: 32.4 years vs. 35.8 years. In total, 84 of the 97 new daily persistent headache patients had no white matter abnormalities or infarct-like lesions on magnetic resonance imaging with a gender distribution of 56 women and 28 men. The mean age of onset of this white matter negative subgroup was 31.1 years. Of these individuals, 36% had cardiovascular/cerebrovascular risk factors and 44% had a history of migraine. Only 13 new daily persistent headache patients (nine women, four men) demonstrated white matter abnormalities on magnetic resonance imaging. None had infarct-like lesions. The mean age of onset of this white matter positive subgroup was 54.2 years, significantly older than the white matter negative population (p <.05). All new daily persistent headache patients in the white matter positive subgroup had cardiovascular/cerebrovascular risk factors and dual risk factors were noted in seven of 13 patients. Only 23% had a migraine history. Almost 40% of the patients in the white matter negative group were imaged 3 years after headache onset and at least six patients were imaged at least 9 years or more after onset of new daily persistent headache. Triggering events in both white matter lesion positive and negative populations were typical of the new daily persistent headache population as a whole and not specific to the presence or absence of brain imaging lesions except for a post-surgery trigger, which was significantly more likely to occur in the white matter positive group. Migraine associated symptoms occurred in 77% of the white matter negative subgroup compared with 46% of the white matter positive subgroup, which was a significant difference. Conclusion White matter abnormalities and infarct-like lesions do not appear to occur in primary new daily persistent headache patients. Only new daily persistent headache patients with risk factors (cardiovascular/cerebrovascular or migraine) developed white matter abnormalities on brain magnetic resonance imaging. No patient with new daily persistent headache developed infarct-like lesions. New daily persistent headache triggering events (outside of possibly post-surgery) or the presence of migrainous symptoms did not appear to enhance the development of white matter abnormalities.