What is Postcraniotomy Headache?
The upper part of the skull, or calvaria, works like a protective box for the brain, while the remaining skull is made up of the facial skeleton. Different bones form various parts of the skull, such as the forehead (frontal bone) the top sides of the skull (parietal bones), and the back of the skull (occipital bone). These bones are connected at joints termed sutures.
When you remove the top of the skull, you can see different areas at the base of the skull, which are crossed by passages or foramina that contain vital nerve and blood vessels passages.
The scalp has five layers, which can be remembered by the acronym “SCALP.” These layers go down from surface to deep and are skin, connective tissue, a thin, tendon-like sheet (aponeurosis), loose connective tissue, and the bony covering of the skull (Pericranium).
An other important structure is the endocranium – a fibrous layer that snugly fits to the skull’s interior surface and also constitutes the outermost layer of the brain covering. There are three protective layers of the brain – dura mater, arachnoid, and pia mater – with the dura mater being the most superficial layer. Brain surgeons often incise the dura mater to access the brain during operations.
Numerous nerves supply the scalp and the dura mater. They include the trigeminal nerve, C1 to C3 nerves, cervical sympathetic trunk, vagus nerve, hypoglossal nerve, facial nerve, and glossopharyngeal nerve.
A craniotomy is a surgical procedure that involves opening part of the skull to access structures within the brain. A common side effect of this procedure is a headache, which can start within a few days after surgery and last less than 3 months. If the headache persists beyond 3 months, it is considered a chronic post-craniotomy headache. Over two-thirds of patients who undergo craniotomy experience this type of headache, which presents unique challenges in diagnosis and management.
What Causes Postcraniotomy Headache?
PCH, or Post-craniotomy Headache, is often caused by a mix of factors. These could include:
* Age: It’s more likely in people under 45.
* Gender: Women are more susceptible.
* Certain types of surgery: Specifically, skull base surgeries that require a lot of muscle dissection.
* Leaking of cerebrospinal fluid (CSF) after surgery: This type of leakage usually reduces when the person is lying down.
* Long surgical procedures: If the operation lasts for more than 4 hours.
* Specific types of tumors: Particularly astrocytomas and brain tumors that have spread from elsewhere.
* Tumor size: Smaller tumors might contribute more to chronic PCH.
* Tumor location: Tumors in certain areas of the brain may increase the risk.
* Certain methods of closing the dura (the outer cover of the brain): Direct closure might lead to more pain compared to using a surgical patch.
* Type of anesthesia: Using inhaled gas may cause more pain than giving medicine through an IV.
* Method of operation: A craniectomy might increase PCH occurrence.
* Existing conditions: Preexisting headache, or unchecked anxiety or depression can exacerbate PCH.
On the flip side, some factors might lower the chance of getting PCH. Cleaning up bone dust after surgery and giving steroids before surgery have been found to possibly reduce the occurrence of PCH.
Risk Factors and Frequency for Postcraniotomy Headache
The actual number of PCH (post-craniotomy headache) cases is not clear due to differences in research methods, inconsistent definitions, and numerous surgical techniques used. However, general studies suggest that more than 30% of patients who have had a craniotomy, a type of brain surgery, experience acute PCH. Chronic PCH, often observed after removing an acoustic neuroma, a type of benign brain tumor, has a rate of about 28.4% three years after the operation.
Signs and Symptoms of Postcraniotomy Headache
People who’ve had recent surgery might experience various types of pain, like constant, throbbing, or pounding headache. This usually starts within a week after the surgery and is typically on the same side where the surgery was done. However, it’s not uncommon for the pain to be felt all over the head. The discomfort could increase initially but then decrease as days pass. Most of the time, post-craniotomy headache (PCH) does not include new sensory or motor problems. When such issues occur, it’s important to consider other potential medical conditions. In addition to the headache, people might also experience nausea, sensitivity to light, anxiety, jaw problems, and depression. The effectiveness of pain relievers and migraine medications differs from person to person.
Moreover, some patients might still have lingering neurological issues even after successful brain surgery. In such cases, the results of their most recent neurological checkup can provide a reference point before conducting a new examination. If there are new signs of neurological problems, further medical evaluations are necessary to rule out other health conditions.
A physical examination of the head and neck might reveal scar neuromas, or nerve tumors, at the site of the surgical scar. When these scars are touched, this can bring back the pain in people experiencing chronic PCH.
Testing for Postcraniotomy Headache
Post-craniotomy headache (PCH) is usually diagnosed by a healthcare professional through direct patient examination. However, if there’s any doubt about the diagnosis, a type of brain imaging called a non-contrast head CT scan (computed tomography) may be suggested. This type of scan can help rule out other potential problems in the brain.
The International Classification of Headache Disorders 3 (ICHD-3) has given some criteria to help doctors diagnose PCH more accurately. These criteria can be divided into two groups, focusing on acute (short-term) and persistent (long-term) headaches following a skull surgery known as craniotomy.
For diagnosing short-term PCH, the headache must have developed within seven days after the surgery or after the patient regained consciousness or stopped taking any medication that could interfere with their headache sensation. This type of headache either eases off within three months of the surgery or hasn’t yet improved but is still within the three-month time frame.
On the other hand, a long-term PCH diagnosis requires the headache to continue past three months following the surgery.
Keep in mind that these criteria should be used only if the headache can’t be attributed to another diagnosed condition.
Statistics show that about a quarter of patients who have short-term PCH end up developing a persistent or long-term version. For patients with persistent headaches post-surgery, there may also be a risk of their headaches being worsened due to the overuse of medications.
For the sake of understanding their pain better, patients suffering from long-term PCH can divide their headache severity into four grades:
Grade 1 refers to a minor inconvenience.
Grade 2 implies experiencing headaches almost daily.
Grade 3 suggests the requirement of medications daily.
Grade 4 means the person is severely hindered due to their headache.
Patients can use tools like the McGill Pain Questionnaire and Brief Pain Inventory scoring system to rate their chronic headaches.
Treatment Options for Postcraniotomy Headache
Research is ongoing to determine the best ways to manage persistent headaches after a head injury, called PCH. Currently, many doctors use medications typically prescribed for headaches. However, certain medications, like opioids, can make it harder to monitor a patient’s neurological responses and can cause addiction and problems with breathing.
If the PCH is severe or sudden, multiple forms of pain relief are suggested, including opioids such as codeine, tramadol, morphine, fentanyl, and remifentanil, and non-opioids like paracetamol, certain anti-inflammatory drugs, dexmedetomidine, gabapentinoids, dexamethasone, and transdermal patches. Combining both opioid and non-opioid medicines can help lessen the risk of side effects. Some examples include fentanyl combined with ketorolac, and tramadol combined with diclofenac.
For chronic PCH, treatment can depend on the cause of the headache. Common treatments include painkillers like paracetamol, codeine, antidepressants, and anti-inflammatory drugs, as well as other medications like Carbamazepine, sodium valproate, gabapentin, lamotrigine, and lignocaine, and treatments like trigger-point injections, topical capsaicin, and botulinum toxin type A. Some surgical techniques, including C2 gangliotomy, C2 ganglionectomy, nerve stimulation, radiofrequency nerve ablation, and cryoablation, may also be used.
Alternative treatment methods that could be considered for patients with chronic PCH include physical therapy, stress management, acupuncture, hot and cold packs, massage, and behavioral interventions. More research is needed to validate the effectiveness of these alternative treatments.
Preventive strategies are also important to manage PCH and reduce the risk of exposure to possibly addictive treatments. This could mean modifying surgical techniques, using preemptive pain management methods such as scalp infiltration, scalp block, and preemptive anti-inflammatory drugs. Anesthetizing certain nerves in the head or administering a one-time dosage of ropivacaine during wound closure may also help.
Other potential preventive treatments include intravenous acetaminophen, levetiracetam, and pre-loperational diclofenac. Some promising treatments still being studied include preincisional infiltration with dexamethasone palmitate emulsion and local infiltration of flurbiprofen axetil. However, it’s important to note that no effective preventive treatments for PCH have been established for the 48-hour period after surgery.
What else can Postcraniotomy Headache be?
When a doctor is trying to diagnose Post-Surgical Cerebrospinal Fluid Leak, it’s important that they also consider other conditions that may have similar symptoms. These can include:
- Hydrocephalus – a buildup of fluid in the brain
- Intracranial hemorrhage – bleeding within the skull
- Different kinds of headaches such as neck-related (cervicogenic), tension, cluster, and migraine
- Headache caused by overuse of medication
- Meningitis or other infections within the skull
- Temporomandibular joint disorder – issue with the joint that connects the jaw to the skull
An in-depth examination and appropriate imaging scans can help a doctor distinguish these conditions from a Post-Surgical Cerebrospinal Fluid Leak.
What to expect with Postcraniotomy Headache
Getting better from post-surgery headaches, or PCH, often improves as the patient recovers from the surgical procedure. But, several factors can impact how fast this happens:
The reason behind the headaches: If severe inflammation is causing headaches, it can take a longer time to get better.
Treatment methods: Not everyone responds to PCH treatments in the same way.
Individual factors: Each person is different, so things like how much pain they can handle, their overall health, and whether they have other medical conditions can affect how long the post-surgery headaches last.
Complications: If problems arise after the surgery, like infections or leaks of brain fluid, it can also affect how fast the patient gets better.
Following treatment instructions: How well the patient follows the care instructions they receive after surgery also plays a role in their recovery from PCH.
Mental and emotional factors: Things like stress and anxiety can influence how a patient perceives and experiences post-surgery headaches.
Patients suffering from post-surgery headaches should always discuss any changes in how they’re feeling or any worries with their healthcare team. Regular check-ups provide chances to assess progress and adjust the treatment plan if needed. This can help to improve recovery outcomes.
Possible Complications When Diagnosed with Postcraniotomy Headache
Acute PCH, also known as sharp head pain, can turn into a chronic, or long-term, condition. Both types of PCH can result in stress, anxiety, and a decrease in the ability to perform daily activities and enjoy life. In addition, the treatment for this condition can sometimes cause repeat headaches and negative medication side effects. If patients mention changes in their pain, it’s important to check for serious conditions like potentially fatal changes in brain pressure and meningitis.
Common Effects of Acute and Chronic PCH:
- Stress
- Anxiety
- Reduced ability to perform daily activities
- Decreased quality of life
- Repeat headaches from treatment
- Negative medication side effects
- Potential for serious conditions if pain changes occur
Preventing Postcraniotomy Headache
To prevent PCH (post-craniotomy headaches), a variety of strategies can be useful. These include:
* Managing pain effectively
* Slowly reducing the usage of pain medication
* Staying well-hydrated
* Moving around early on to relax tense muscles
* Using preventive medication, as previously mentioned
* Using caffeine wisely to avoid experiencing withdrawal symptoms
* Having regular doctor’s appointments
* Finding ways to manage stress
* Addressing any problems with sleeping
* Figuring out and avoiding things that trigger headaches
Doctors should work together with patients to create a tailor-made plan that works best for them and supports their recovery after brain surgery.
