Persistent post‑craniotomy headache: a narrative review
Christoper A. Alarcon‑Ruiz1,2, Maria Teresa Goicochea3
¹Instituto Nacional de Ciencias Neurologicas, Lima, Peru
²Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Peru
Introduction
Persistent post-craniotomy headache (PPCH) is a frequent yet underrecognized
complication of cranial surgery, often leading to long-term disability and impaired
quality of life. Defined as a headache developing within seven days of craniotomy
and lasting more than three months, the true PPCH prevalence and incidence
remains unclear and varied widely across studies and time windows. Despite its
impact, the condition remains poorly understood, and standardized diagnostic and
therapeutic protocols are lacking.
Review
PPCH arises from multifactorial mechanisms, including direct nerve injury, muscle
adhesion to the dura mater, aseptic inflammation, and central sensitization.
Five main phenotypes can be identified: scar-related neuropathic pain, occipital
neuralgia–like headache, diffuse tension-type pattern, migraine-like phenotype,
and mixed presentations. Risk factors include posterior fossa and suboccipital
surgeries, pre-existing migraine, female sex, inadequate perioperative analgesia,
and psychological comorbidities such as anxiety or depression. Evaluation must rule
out secondary causes through clinical examination and selective imaging. Treatment
should follow a multimodal, phenotype-driven approach combining pharmacologic
agents with interventional procedures such as peripheral nerve blocks or scartargeted
botulinum toxin A injections. Surgery is reserved for refractory, well-defined
cases involving neuromas or hardware irritation.
Conclusions
PPCH represents a complex chronic secondary headache condition that demands
systematic identification and personalized, stepwise management. However,
evidence remains limited, and prospective multicenter studies with standardized
definitions and outcomes are urgently needed to improve prognosis and quality of
life for affected patients.