Persistent post‑craniotomy headache: a narrative review

Abstract

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 prevalence, 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 scar-targeted 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.