Post-craniotomy Headaches After Surgery

Abstract & Commentary

By Dara G. Jamieson, MD, Associate Professor, Clinical Neurology Director, Weill Medical College, Cornell University. Dr. Jamieson is a consultant for Boehringer Ingelheim and Merck, and is on the speaker's bureau for Boehringer Ingelheim, Merck, Ortho-McNeil, and Pfizer.

Synopsis: Acute and chronic head and face pain occur after craniotomies for a variety of intracranial lesions. Persistent postoperative pain is more common in women and is associated with depression and anxiety.

Sources: Rimaaja T, Haanpää M, Blomstedt G, et al. Headaches after acoustic neuroma surgery. Cephalalgia 2007;27:1128-1135; Rocha-Filho PA, Gherpelli JL, de Siqueira JT, et al. Post-craniotomy headache: characteristics, behaviour and effect on quality of life in patients operated for treatment of supratentorial intracranial aneurysms. Cephalalgia 2007;28:41-48; Rocha-Filho PA, Fujarra FJ, Gherpelli JL, et al. The long-term effect of craniotomy on temporalis muscle function. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e17-e21.

Some neurosurgical patients leave the hospital with more than just a scalp scar and the reassurance of having a resected acoustic neuroma or a clipped aneurysm. Post-craniotomy headaches can be frustrating for neurosurgeons and their referral neurologists, but are especially so for patients who thought that brain surgery would end their neurological symptoms. The International Headache Society (IHS) recognizes chronic post-craniotomy headache as a headache, maximal in the surgical area, that develops within 7 days of the craniotomy and persists for at least 3 months. An acute post-craniotomy headache has the same characteristics but lasts for less than 3 months. Both supra- and infratentorial surgeries for multiple types of intracranial lesions can cause craniofacial pain that persists postoperatively. These three papers, two from the University of San Paulo and one from Helsinki University, review the chronic head and face pain syndromes that can result from craniotomy.

Rimaaja and researchers noted that preoperative headaches occur in a variable percentage of patients undergoing acoustic neuroma surgery, but postoperative headaches persist in up to one-third of patients a year after resection. The aim of this study, which reviewed the charts of 241 patients who underwent acoustic neuroma surgery from January 1995 to September 2002 at Helsinki University Hospital, was to assess headaches after the operation. The authors sent out questionnaires to evaluate pre- and postoperative headache characteristics as well as symptoms of depression in 228 living, traceable patients, of whom 84% responded. About one-third of patients had preoperative headaches, but twice that number had postoperative headaches. Of the 122 patients who reported any postoperative headache, 110 noted either only post-craniotomy headaches or distinctly different, new post-craniotomy headaches. Three quarters of the patients with new post-operative headaches had headaches that persisted for at least a year after surgery. Possible predictors of chronic postoperative headache were female gender (p=0.04), lack of previous headache (p=0.005), and small tumor size (p<0.0001). All patients with new postoperative headaches had acoustic neuroma resection with a retrosigmoid approach. Of the new postoperative headache patients, one-third of those with continuing headaches had depression; however, only 9% of the patients without continuing postoperative headaches had depression, as assessed by the Beck Depression Inventory. Physical stress, bending, or coughing typically aggravated the headaches, which may relate to sensitization of dural sensory pathways. The authors suggested simple analgesics for acute pain relief and tricyclic antidepressants or gabapentin for preventative therapy.

Rocha-Filho and coworkers evaluated craniofacial pain after resection of supratentorial cerebral aneurysms. In one paper, they retrospectively evaluated the jaw movements and masticatory muscles of 71 patients at 4-6 months after craniotomy by a pterional approach. About 48% of post-craniotomy patients complained of craniofacial pain with normal jaw movement or activities. More than half of the patients complained of pain in muscle of mastication. Those patients with post-craniotomy headache were more likely to have marked masticatory muscle tenderness than those without headache after surgery.

The same group at the University of San Paulo prospectively followed 79 patients who survived operative treatment of a supratentorial aneurysm between October 2002 and October 2003. The patients, who all had a Glasgow Coma Scale score of 15 prior to surgery, were divided into a group without subarachnoid hemorrhage (SAH), a group with SAH but no pre-operative headache, and a group with SAH and a preoperative headache. They were followed for up to 6 months after surgery, with chronic post-craniotomy headaches defined by IHS criteria as occurring at 3 months. Headaches were observed in more than 90% of patients after surgery, decreasing to 60% at a week postoperatively. An increase in mean headache frequency was observed postoperatively, with a decrease in headache frequency over time in all study groups. Using IHS criteria, the incidence of acute (< 3 months) post-craniotomy headache was 10.7%, with a 29.3% incidence of chronic (> 3 months) headache. Headaches were both migrainous and non-migrainous in description. While 40% of patients who did not have SAH had chronic post-craniotomy headache, almost all of those patients had a primary headache disorder prior to aneurysm resection. Increasing the time period for the onset of post-craniotomy headache from 7 days to 30 days increased the number of patients defined as suffering from a post-craniotomy headache. There was a significant, positive correlation between anxiety and depression and headache frequency. Pain intensity was higher in women and in patients with more symptoms of anxiety. Post-craniotomy headache had significant negative effects on patients' quality of life.

Commentary

These two groups published papers that assessed the prevalence and characteristics of post-craniotomy headaches associated with different intracranial lesions. Any evaluation of a post-craniotomy headache must take into account the high prevalence of primary headaches (migraine and tension-type) in the population, as well as the headaches associated with the underlying intracranial lesion that necessitated surgery. However, chronic headaches related to the surgery commonly occur in patients after craniotomy. While a rare immediate postoperative headache may be due to surgical complications, the vast majority of acute and chronic post-craniotomy headaches have no underlying anatomic correlate and may be related to a disturbance of dural nociceptive receptors. Patients should be prepared prior to surgery for the possibility of persistent headaches, and given reassurance that headaches developing after surgery are expected and treatable. Recognition of the common occurrence of these post-craniotomy headaches can forestall unnecessary invasive interventions to diagnose or treat the acute or chronic headache precipitated by neurosurgery.