Post-Craniotomy Headache: Current Concepts and Emerging Procedural Therapies

Abstract

Post-craniotomy headache (PCH) is a common complication following neurosurgery, yet there remains limited consensus regarding the mechanism, classification, and optimal management. This review summarizes the current literature and highlights recent trends in procedural therapies. PCH occurs in approximately 60–70% of patients following craniotomy, with nearly 25% progression to persistent PCH. Identified risk factors include younger age, female sex, pre-existing headache disorders, and longer operative duration. Some studies further characterize PCH into migrainous, tension-type, cervicogenic, or neuropathic phenotypes, however classification remains inconsistent across the literature. Pharmacological treatment largely extrapolates from migraine and neuropathic pain management, though emerging evidence in the last few years supports the potential role of onabotulinumtoxinA and nerve blocks. Current evidence supports the use of pharmacological, nonpharmacological, and procedural interventions to treat PCH. Future research should prioritize a phenotype-driven approach, evaluation of standardized multi-modal protocols, as well as novel therapies, including calcitonin gene-related peptide (CGRP)-targeted agents.