Expanding Our Role in Headache Management: A Systematic Review and Algorithmic Approach to Surgical Management of Postcraniotomy Headache

PURPOSE: The International Classification of Headache Disorders (ICHD) defines chronic postcraniotomy headache (PCH) as a “secondary headache persisting for longer than three months following a craniotomy.” 1 Chronic PCH is unfortunately common and debilitating, with an incidence as high as 64%.2 However, the literature on this topic is sparse without clear management algorithms. 2–5 Possible etiologies of PCH include nerve injury and/or entrapment, hardware, dural adhesions, or musculoskeletal injury. The purpose of this study is to present the results of both a systematic review of the literature and a single-center case series for patients surgically managed for chronic PCH, both of which informed the development of a novel treatment algorithm that may be applied to this patient population METHODS: Using PRISMA guidelines, we performed a systematic review of the literature, identifying articles describing the surgical management of PCH. Searches used a combination of the terms “neurosurgery,” “craniotomy,” “headache,” and “pain.” A retrospective chart review was performed to identify patients who met the criteria for surgical PCH treatment at a single institution between January 2013 to July 2021. A patient’s history and physical exam determined the etiology and management, and pain severity scores were the primary outcomes measured. RESULTS: Nineteen papers encompassing 131 patients described surgical management techniques for PCH. Analysis of improvement of pain after intervention in the literature demonstrated that 83 patients (63%) had complete resolution of pain, 23 patients (18%) had significant improvement, and 25 patients (19%) had no improvement (X2 =52.1, p< 0.001). At our institution, 19 patients underwent surgical management for PCH. Headache duration ranged from 3.6 months to 12.1 years, with a mean duration of 3.4 ± 3.1 years. A significant reduction in pain scores from 7.57 to 2.16 (p< 0.001) was demonstrated, and eighty-four percent of patients achieved complete or significant pain reduction. The average duration of follow-up was 1.4 ± 1.18 years. CONCLUSIONS: Through a literature review and our own case series, we demonstrate that surgical management of PCH can achieve remarkable results with significant improvement in pain. Plastic surgeons, with their expanding role in treating migraine and headaches, are well-suited to manage these patients. We present an algorithmic approach to simplify the management of this common and debilitating condition. References: 1. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629-808. doi:10.1177/0333102413485658 2. Rocha-Filho PAS, Gherpelli JLD, de Siqueira JTT, Rabello GD. Post-craniotomy headache: Characteristics, behaviour and effect on quality of life in patients operated for treatment of supratentorial intracranial aneurysms. Cephalalgia. 2008;28(1):41-48. doi:10.1111/j.1468-2982.2007.01465.x 3. Schaller B, Baumann A. Headache after removal of vestibular schwannoma via the retrosigmoid approach: A long-term follow-up-study. Otolaryngology - Head and Neck Surgery. 2003;128(3):387-395. doi:10.1067/mhn.2003.104 4. Schessel DA, Nedzelski JM, Rowed D, Feghali JG. Pain after Surgery for Acoustic Neuroma. Otolaryngology–Head and Neck Surgery. 1992;107(3):424-429. doi:10.1177/019459989210700314 5. Rocha-Filho PAS. Post-Craniotomy Headache: A Clinical View With a Focus on the Persistent Form. Headache: The Journal of Head and Face Pain. 2015;55(5):733-738. doi:10.1111/HEAD.12563