Continuing Education Activity

A craniotomy is a neurosurgical technique, whereby part of the skull is opened or removed for intracranial access to treat conditions such as brain tumors, aneurysms, and arteriovenous malformations. Post-craniotomy headaches (PCH) are one of the most frequently encountered adverse events after craniotomy, presenting in over two-thirds of patients who have undergone the procedure. PCH falls under the category of secondary headaches and can present unique challenges in diagnosis and management. This activity reviews the current literature on post-craniotomy headaches and highlights the role of the interprofessional team in ensuring appropriate evaluation and management of affected patients.

Objectives:

• Describe the most commonly occurring post-craniotomy complications.
• Review post-craniotomy headaches from potentially life-threatening complications of craniotomy.
• Outline a post-craniotomy patient complaining of a headache.
• Explain the need for optimizing care coordination, with particular emphasis on communication between interprofessional medical teams, to enhance prompt evaluation and management of post-craniotomy headaches and decrease the likelihood of missing a potentially life-threatening complication of craniotomies.

Introduction

A craniotomy is a neurosurgical technique, whereby part of the skull is opened or removed for intracranial access to treat conditions such as brain tumors, aneurysms, and arterio-venous malformations. Post-craniotomy headaches (PCH) are among the most frequently encountered adverse events after craniotomy, appearing in over two-thirds of patients undergoing the procedure.[1] PCH falls under the category of secondary headaches and can present unique challenges in diagnosis and management.[2] This article gives a brief overview of the current literature regarding this headache subtype.

Etiology

There are many hypotheses of which can contribute to the pain response following craniotomy. One of the more straightforward mechanisms is the direct trauma from the surgery itself to the soft tissue, musculature, bone, or meninges. Other potential causes include nerve injury, debris from drilling bone irritating the internal structures and meninges, muscle adherence to the dura mater, formation of neuroma in the surgical scar, central sensitization, and aberrant nerve regeneration.[3]

Risk factors for PCH may include age, gender, and the previous history of headaches, all of which have been disputed and remain in question. However, neurosurgical duration of greater than 4 hours has been associated with a higher prevalence of PCH. Some studies suggest that incidence increases with specific surgical approaches, for example, craniectomies have a higher incidence than craniotomies or cranioplasties, and the suboccipital approach has a higher incidence than the translabyrinthine approach.[4][5]

Although psychiatric disorders are not risk factors for PCH, the presence of uncontrolled anxiety or depression may increase the intensity and frequency of PCH, while worsening quality of life.[6]

Epidemiology

Unfortunately, due to methodological differences, inconsistencies in definition, and multiple surgical approaches, retrospective reviews found an incidence range ranging from zero to 100%. However, looking broadly, a majority of those studies report that greater than 30% of craniotomy patients suffered from PCH.[7]

Chronic PCH, which is commonly seen with excision of acoustic neuromas, has an incidence of 28.4% at three years postoperatively.[8]

History and Physical

An accurate description of PCH has been scant and perhaps nonspecific. Still, some research suggests that on history, patients may report a continuous, pulsatile, or pounding pain of variable intensity that appears within seven days of the surgery. Other common characteristics include symptoms on the same side as the surgical incision and improvement of symptoms over time.[6]

As with all headaches, it is imperative to rule out red flag signs including but not limited to paralysis, papilledema, drowsiness, confusion, memory impairment, loss of consciousness, focal neurologic signs, neck stiffness, sudden onset excruciating pain, or personality changes.

Some evidence points to scar neuromas as a potential trigger for headaches. Thus, it is essential to assess the scar site on the physical exam and evaluate the reproduction of headache pain with palpation.[9]

Evaluation

PCH is primarily diagnosed through history and physical examination. However, imaging may be warranted if intracranial pathology is suspected or red flags are found on examination. If so, a non-contrast head CT scan would be an appropriate first step.

According to the International Classification of Headache Disorders 3 Beta edition, the current criteria for diagnosis are as follows:

A. Any a headache fulfilling criteria C and D

B. Surgical craniotomy has been performed

C. A headache is reported to have developed within seven days after one of the following:

• The craniotomy
• Regaining of consciousness following the craniotomy
• Discontinuation of medication(s) that impair the ability to sense or report a headache following the craniotomy

D. Either of the following:

• A headache has resolved within three months after the craniotomy
• A headache has not yet resolved but three months have not yet passed since the craniotomy

E. Not properly accounted for by another ICHD-3 diagnosis.

Of note, persistent headache attributed to craniotomy differs from the acute headache criteria by the fact that it persists for more than three months after the craniotomy. About a quarter of patients who develop an acute headache attributed to craniotomy experience a persistent headache attributed to craniotomy. When a headache following craniotomy becomes persistent, the possibility of a medication-overuse headache should be considered.[10]

Treatment / Management

Unfortunately, research remains lacking in regards to current strategies to manage PCH. Therefore, options for consideration include using typical medications seen in the treatment of headaches with similar phenotypes. A list of these medications is beyond this review's scope, but, in the neurological population, care must be taken when using medications that may obscure the ability to monitor neurologic responses.[11]

This is of particular importance when opioids are prescribed. They remain a heavily relied upon option for moderate to severe pain, even with the risk of addiction, cognitive clouding, and respiratory depression. Worth noting is the ability to combine other analgesics with opioids to lessen the chance of adverse events. Some combinations in past studies include fentanyl and ketorolac or tramadol and diclofenac.[8]

Regarding prophylaxis, one single-center, randomized, the blinded trial found that a preoperative dose of 100 mg of diclofenac decreased the headache's intensity on postoperative day one and up to post-op day 5 for patients with infratentorial surgeries. Still, caution must be exercised due to the potential to increase the risk of bleeding using non-steroidal anti-inflammatory medications.[1]

Other interventions have been studied, either for PCH or post-craniotomy pain in general, but warrant more research before standardizing their use in these patients. These include transcutaneous electrical acupuncture stimulation, nerve blocks, gabapentinoids, COX inhibitors, and dexmedetomidine, a presynaptic alpha two adrenoceptor antagonist.

In the chronic phase, a shift to more non-pharmacological adjuncts may be considered. Alternatives to consider are physical therapy, acupuncture, TENS units, hot or cold packs, massage, or bio-behavioral interventions. A small case series of four patients demonstrated a benefit using Botulinum toxin-A to treat delayed onset PCH, but more research is needed, similar to the other treatments.[1]

Differential Diagnosis

• Post-surgical cerebrospinal fluid leak
• Hydrocephalus
• Intracranial hemorrhage
• Other headache types including cervicogenic, tension, cluster, and migraine
• A medication-overuse headache
• Meningitis or other infection
• Temporomandibular joint disorder

Pearls and Other Issues

• PCH appears in over two-thirds of patients undergoing the procedure. 
• Diagnosis is made primarily through the use of ICHD 3-beta criteria.
• Risk factors include a choice of surgical approach and length of surgery. 
• Anxiety and depression may exacerbate symptom intensity.
• Management in the acute phase may be best guided by the treatment of headaches of a similar phenotype.
• Management in the chronic phase may best be achieved through non-pharmaceutical adjuncts.

Enhancing Healthcare Team Outcomes

Post craniotomy is quite common after surgery, but making the diagnosis is difficult as there are many serious causes of headaches post craniotomy, which first needs to be ruled out. The condition is best managed by an interprofessional team that includes a neurosurgeon, neurologist, internist, pharmacist, and a mental health nurse. Once the severe causes have been ruled out, it is best to use non-pharmacological therapy to relieve the headaches. The use of narcotics in post craniotomy patients is not recommended. Psychotherapy or some cognitive-behavioral therapy may be useful.