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Abstract

Introduction

Headache is the most common adverse event immediately following craniotomy and is due to the surgical procedure and meningeal irritation.

Objectives

The aim of this study was to investigate the prevalence of headache during the first week after a craniotomy, as well as headache intensity, whether pain was registered in the patient's medical records, the use of analgesics and predictors of headache.

Methods

Ninety-one patients who underwent craniotomy were evaluated from the first to the seventh post-operative day. The variables analysed were gender, age, medical history, indication for craniotomy, surgery, occurrence of headache, pain registration in the medical records, length of hospital stay and analgesics consumption.

Results

On the second post-operative day, 29.2% of patients had a headache and there was under-reporting of this pain in the patients’ records. The analgesics used were non-steroidal anti-inflammatory in 75% of cases. An age of <45 years (odds ratio = 3.0, p = 0.041) and surgery duration lasting >4 hours (odds ratio = 3.7, p = 0.019) were associated with the occurrence of immediate post-craniotomy headache.

Conclusion

Further training should be provided to professionals caring for patients undergoing craniotomy to better manage post-operative headache.

Keywords

Craniotomy headache pain

Introduction

Craniotomy is indicated for traumatic brain injury, brain tumours, aneurysms and arteriovenous malformations. In general, the technique involves creating an opening in the skull to access the meninges and brain mass (1). As a result of the surgical procedure, many patients experience headache episodes in the post-operative period, with an incidence ranging from 5% to 91% (2,3).

According to the International Headache Society (IHS) (4), the definitive diagnosis of post-craniotomy headache (ICHD-II 5.7) depends on the onset of pain within 7 days after surgery, which can be of variable intensity. In addition, the craniotomy should have been performed for a reason other than brain trauma. The classification of pain as acute (ICDHD-II 5.7.1 G44.880) or chronic (ICDH-II 5.7.2 G44.30) depends on its duration and has a 3 month post-craniotomy period as a cut-off point (4).

Although an immediate headache is not included as a diagnostic subtype, the IHS reports that up to 80% (4) of patients experience episodes of headache in the first hours after craniotomy and this symptom improves during the first post-operative week in most cases. The present study is motivated by the current limitations in the understanding of immediate post-craniotomy headache and, in particular, its occurrence, characterisation, pain management and factors that predict its onset.

The lack of brain tissue sensitivity due to the absence of nociceptors in its parenchyma, and innervation virtually limited to the meninges and extracranial muscles and fascia, has led to the belief that patients would experience minimal pain following craniotomy. Therefore, the use of post-operative analgesics has received little attention (5). However, two-thirds of patients experience moderate to severe pain post-craniotomy, especially in the first 48 hours after surgery (6). Therefore, adequate pain control is an important matter for the patient and health care provider.

Although the pathophysiological mechanisms of headache after craniotomy need to be elucidated, inflammation and meningeal fibrosis, compression and entrapment of nerves and the formation of traumatic neuromas are thought to be commonly associated factors (7). Surgical incision and other adverse perioperative events can also induce changes in central neural function through phenomena such as sensitisation and wind-up, which contribute to the pathogenesis of the post-operative pain (8 –10).

This study aimed to investigate headache prevalence immediately after craniotomy (up to 1 week post operation), headache pain intensity, the incidence of pain registration in the medical records, the prescription of analgesics and the factors associated with the occurrence of headaches.

Methods

Study design

Between September 2010 and October 2011, a prospective study was conducted with patients undergoing elective craniotomy in the Neurology Sector of the Charitable Hospital Foundation for Surgery, Sergipe, Brazil.

Participants

A total of 91 patients were included. Patients with less than 15 points on the Glasgow Coma Scale (GCS) at the time of evaluation, victims of traumatic brain injury, patients who subsequently died and patients aged <18 years were excluded from the study. All patients gave informed consent before being enrolled in the study. Study approval was obtained from the Committee for Ethics in Medical Research of the Federal University of Sergipe.

Variables

Document analysis and semi-structured interviews were used to collect data, including demographic variables, medical history, indication for craniotomy, surgery, duration of hospital stay, occurrence of headache, registry of pain in their medical records and consumption of analgesics.

Diagnosis of immediate post-craniotomy headache

For the diagnosis of immediate post-craniotomy headache, the following IHS criteria were used: headache of variable intensity with maximum intensity in the area of the craniotomy; craniotomy performed for a reason other than head trauma; the headache must have occurred within 7 days after the craniotomy.

The intensity of the headache was analysed by means of a 0–10 numerical rating scale and categorised according to the International Association for the Study of Pain (IASP; 11): no pain = 0; mild pain = 1–3; moderate pain = 4–7; severe pain = 8–10.

Setting

In accordance with the local protocol, all patients received nerve block anaesthesia and 10 mg morphine i.v. bolus during the perioperative period. As this drug can have satisfactory analgesic effects up to 24 hours after its administration in craniotomy cases (12), the patients were evaluated every day from the first 24 hours (day 1) until the seventh day (day 7) of post-operative care or hospital discharge.

Data collection occurred before the patients underwent the craniotomy. These patients were also monitored in the first 24 hours post-surgery (day 1) and until the seventh day after the craniotomy (day 7), unless the patient was discharged before day 7. The presence of headaches and their intensity were investigated.

Assessment of analgesic consumption

The prescription of analgesics (non-steroidal anti-inflammatory drugs (NSAIDs), weak opioids and strong opioids) was recorded at all times during the study (days 1–7). For those patients who received analgesic medication, we evaluated the intensity of the headache before and after 1 hour of medication administration. For patients who received no pain medication, a period of 1 hour was also adopted as the standard for reassessing the severity of the headache.

Statistical methods

Data were stored in the OriginPro 8.0 SRO® software (OriginLab Corporation, Northampton, MA, USA) for the analysis of descriptive (frequency, measures of central tendency and dispersion) and inferential statistics. Point prevalence was used as a measure of the proportion of people in the study who had a headache at a particular time and took into consideration the number of patients diagnosed with headache and the total number of patients hospitalised at the time of evaluation.

Pain intensity comparison before and after the use of analgesics was performed using a one-sided paired t-test. Pain reduction at the time of reassessment between the patients who received analgesics and those who did not was performed by one way analysis of variance. A Fisher's exact test was used to detect differences between patients treated with analgesics and untreated patients at day 1. A p-value <0.05 was deemed to be statistically significant.

A multiple logistic regression model was developed to determine factors that could explain the presence of immediate post-craniotomy headache. The logistic regression model used was taken from epidemiological studies and, in this case, the binary response was the presence or absence of a headache and the predictive variables were the risk factors and possible confounding variables (13). The following pre-specified variables were selected as potential predictors for immediate post-craniotomy headache: gender; age (>45 years or ≤45 years); presence of preoperative pain (yes or no); use of preoperative analgesic (yes or no); indication for craniotomy, surgical approach (infratentorial or supratentorial); surgery duration (>4 hours or ≤4 hours). Variables with a p-value <0.25 in the univariable logistic regression were retained for adjustment and the final model was found by a backward selection of predictor variables, as described by Hosmer and Lemeshow (13). At each step, the variable providing the highest p-value was deleted from the model. Variables were kept in the final model if the p-value was <0.05.

Results

A total of 116 patients were eligible for the study. However, 25 participants were excluded due to death (n = 2), by showing less than 15 points in the GCS (n = 17) or because they were aged <18 years (n = 6). The final cohort consisted of 91 patients, 56 women and 35 men. Ages ranged from 18 to 69 years, with an average of 44.8 years. A total of 63.8% of patients had no history of systemic disease, 27.5% had a history of hypertension, 5.5% had diabetes mellitus, 2.2% had both those diseases and 1% had heart disease. In more than half of the cases (60.4%), the craniotomies were performed due to the presence of a brain tumour and 39.6% were due to a non-ruptured aneurysm. The supratentorial surgical approach was performed in 91.2% of the cases and the majority of surgeries lasted between 3 and 4 hours (3.5 ± 2.8 hours). A total of 86 patients were admitted to the Intensive Care Unit (ICU), with a mean stay of 2.8 days. The total average hospital stay was 16.5 days. No patient had a post-operative infection.

The data show that, among the 91 patients who participated in the study, some patients could not be monitored over the entire follow-up period because they were discharged from the hospital before the end of the study. On day 2 and day 3, four patients were discharged; on day 4 and day 5, 16 patients were discharged; on day 6 and day 7, 29 patients were discharged (Figures 1 and 2).

Figure 1.

Point prevalence of immediate post-craniotomy headache. Grey bars indicate the number of patients on each day of evaluation. The loss of follow-up refers to the number of hospital discharges in each period.

Figure 2.

Registration of pain in the medical records of patients with immediate post-craniotomy headache and analgesic usage.

Preoperative pain

A total of 60.4% of the patients examined complained of preoperative headache (Table 1). Preoperative headache was recorded if it was continuous and interfered with the patient's daily activities. There was no report of nausea, vomiting or visual changes.

Table 1.

Variables associated with preoperative pain in the head region of patients undergoing elective craniotomy.

Variable	n	%
Preoperative pain
Yes	55	60.4
No	36	39.6
Pain intensity
Mild (1 –3)	2	3.6
Moderate (4 –7)	9	16.4
Intense (8 –10)	44	80.0
Analgesic use
Yes	42	76.4
No	13	23.6
Type of analgesic
Simple analgesic/NSAIDS	41	97.6
Weak opioid	1	2.4
Strong opioid	–	–
Frequency of analgesic use
Single dose	30	71.4
Every 6 hours	2	4.8
Every 12 hours	3	7.1
Other	7	16.7

NSAIDs: non-steroidal anti-inflammatory drugs.

It is important to emphasise that the preoperative headaches reported by the patients were progressive; they were worse in the morning and were aggravated by coughing and forward tilting of the head. Furthermore, all the patients were diagnosed with neoplasia on the basis of the results of the imaging studies. All of the patients used corticosteroids in the pre-and post-operative periods. These observations are consistent with the criteria established by the IHS (4) regarding the classification of Headache Attributed Directly to Neoplasm.

In 80% of cases, the headache was severe and the vast majority used NSAIDS for pain control. The majority of patients (76.4%) took analgesics only when they felt pain (Table 1).

Prevalence of immediate post-craniotomy headache and pain registration

Of the patients who underwent elective craniotomy, 24.2% had a headache at the first evaluation (day 1). The headache prevalence did not vary significantly over time, but was slightly higher on day 2 (29.2%) and slightly lower on day 5 (14.1%; Figure 1). The post-craniotomy headache was recorded if it was continuous and interfered with the patient's daily activities; there was no report of nausea, vomiting or visual changes. Although headache is a frequent complaint in the first post-surgical days, it is commonly under-reported in patient medical records (Figure 2).

Post-surgery analgesic consumption

Although headache was a common complaint in the first post-operative week, the regular prescription of analgesics was uncommon (Figure 2). Analgesics use was independent of gender, age, preoperative pain, indication for craniotomy, surgical approach and duration of surgery (Table 2). Table 3 shows intra-group comparison of headache intensity at the time of assessment and reassessment. There was a significant decrease in pain intensity in the group of patients who received analgesic medication and in the group that received no medication for almost all follow-up times (Table 4).

Table 2.

Characteristics of patients with headache with and without the use of post-operative analgesics at the first evaluation (day 1).

Characteristics	Group 1 (n = 9) (untreated)	Group 2 (n = 13) (analgesic consumption)	p-value
Gender
Female	7	9	1.000
Male	2	4	1.000
Age (years)
≤45	6	10	0.655
>45	3	3	0.655
Preoperative pain
Yes	5	9	0.662
No	4	4	0.662
Indication of craniotomy
Brain tumour	5	9	0.662
Unruptured aneurysm	4	4	0.662
Surgical approach
Supratentorial	9	12	1.000
Infratentorial	–	1	1.000
Surgical time (hours)
≤4	5	6	1.000
>4	4	7
Headache severity (mean ± SD)	5.1 ± 2.7	6.8 ± 2.7	0.162
Use of analgesics
NSAIDS	–	10	N.A.
Opiates	3

NSAIDs: non-steroidal anti-inflammatory drugs; N.A.: not applicable.

P-values for the Fisher's exact test (nominal variables) and a one-sided t-test for independent samples (measurement variables). P-values < 0.05 were considered statistically significant.

Table 3.

Intra-group comparison of headache intensity at the time of assessment and reassessment.

Days	Pain intensity of the headache	Group 1 (untreated)		p-value	Group 2 (treated with analgesics)		p-value
Evaluation	Revaluation	Evaluation	Revaluation
Day 1	6.1 ± 2.8	5.1 ± 2.7	5.1 ± 2.7	N. S.	6.8 ± 2.7	4.6 ± 3.0	<0.0001
Day 2	5.0 ± 2.5	4.1 ± 1.8	4.1 ± 1.8	N. S.	5.8 ± 2.9	3.2 ± 3.4	<0.0001
Day 3	6.1 ± 2.1	5.9 ± 2.1	5.5 ± 2.4	0.001	6.3 ± 2.2	3.8 ± 2.4	<0.0001
Day 4	5.8 ± 2.4	5.3 ± 2.9	4.5 ± 3.5	0.006	6.1 ± 2.2	3.8 ± 3.1	<0.0001
Day 5	3.5 ± 1.6	3.5 ± 1.7	2.6 ± 1.7	<0.0001	4.8 ± 2.0	1.6 ± 1.4	0.0058
Day 6	5.4 ± 2.1	4.6 ± 1.9	3.4 ± 2.5	0.005	5.8 ± 2.3	3.7 ± 2.2	<0.0001
Day 7	5.7 ± 3.2	2.5 ± 0.0	2.5 ± 0.0	N. S.	7.4 ± 2.7	6.0 ± 3.2	0.0005

Group 1: patients who did not use analgesic medication; Group 2: patients who used analgesic medication.

P-values were calculated using one-sided paired t-tests. P-values < 0.05 were considered statistically significant.

Pain intensity: no pain = 0; mild pain = 1-3; moderate pain = 4-7; severe pain = 8-10.

Table 4.

Pain reduction between groups at the time of reassessment.

Days	Group 1 (untreated)	Group 2 (treated with analgesics)	p-value
Day 1	0.0 ± 3.3	2.2 ± 3.8	N. S.
Day 2	0.0 ± 2.7	2.6 ± 3.5	N. S.
Day 3	0.4 ± 3.0	2.5 ± 3.0	N. S.
Day 4	0.8 ± 3.6	2.3 ± 3.2	N. S.
Day 5	0.9 ± 2.6	3.2 ± 2.6	N. S.
Day 6	1.2 ± 3.0	2.1 ± 3.0	N. S.
Day 7	0.0 ± 0.0	1.4 ± 3.4	N. S.

Group 1: patients who did not use analgesic medication; Group 2: patients who made use of analgesic medication.

P-value for the one way analysis of variance. P-values < 0.05 were considered statistically significant.

Pain intensity: no pain = 0; mild pain = 1-3; moderate pain = 4-7; severe pain = 8-10.

However, when comparing the average pain intensity between the groups at the time of reassessment, there was no statistical significant difference at any time (Table 4). A possible explanation for this is that the majority of patients used NSAIDS (75%) for the study period. In 25% of cases, weak opioids were prescribed to patients with headache. In these cases, the intensity of pain was notably lower than in the group of untreated patients (day 1: 2.5 ± 2.7 vs. 5.1 ± 2.7; day 2: 1.0 ± 1.4 vs. 4.1 ± 1.8; day 3: 2.5 ± 2.7 vs. 5.5 ± 2.4; days 4 and 5: no patients were treated with opiates; day 6: 2.0 ± 0.0 vs. 3.4 ± 2.5; day 7: 2.0 ± 0.0 vs. 2.5 ± 0.0); however, no statistical tests were performed because a very small number of patients used opiates.

Univariate and multiple logistic regression analysis

In univariate analysis, female gender, aged <45 years and a surgical duration >4 hours were independently associated with immediate post-craniotomy headache (Table 5). The significant variables after backward elimination formed the final logistic regression model (Table 6). In multivariate analysis, only an age <45 years (odds ratio (OR) = 3.00, p = 0.041) and a duration of surgery >4 hours (OR = 3.74, p = 0.019) were kept in the model as significant covariates of immediate post-craniotomy headache (Table 7). In the presence of these covariates (P = e⁻^3.052^+1.093X₂ ^+1.320X₃ / 1 + e⁻^3.052^{+ 1.093X₂} ^{+ 1.320X₃} ), the probability of occurrence of headache immediately after craniotomy is approximately 34.5%.

Table 5.

Univariate analysis of potential predictors of immediate post-craniotomy headache.

Immediate post-craniotomy headache
Potential predictors	Yes (n = 22)	No (n = 69)	OR (95% CI)^a	p-value
Gender
Female	16	40	1.93 (0.67–5.54)	0.219^b
Male	6	29
Age (years)
≤45	16	31	3.26 (1.14–9.35)	0.027^b
>45	6	38
Preoperative pain
Yes	14	41	1.19 (0.44–3.23)	0.724
No	8	28
Preoperative analgesic
Yes	12	31	1.47 (0.56–3.86)	0.432
No	10	38
Indication of craniotomy
Brain tumour	14	41	1.19 (0.44–3.23)	0.724
Unruptured aneurysm	8	28
Surgical approach
Supratentorial	22	61	26450.8 (0.00-α)	0.860
Infratentorial	0	8
Surgical time (hours)
≤4	9	44	2.54 (0.95–6.78)	0.062^b
>4	13	25

Odds ratio (OR) for potential predictors and 95% confidence interval (CI).

Variables associated with immediate post-craniotomy headache in univariate analysis with p < 0.25.

Table 6.

Backward selection.

Covariates	R	F	p-value
Female gender × age ≤45 years × surgical time >4 h	0.343	3.872	0.011^a
Age ≤45 years × surgical time >4 h	0.307	4.595	0.012^a
Age ≤45 years	0.238	5.352	0.021^a

R: coefficient of determination; F: coefficient calculated by the Fisher-Snedecor distribution.

Variables with p-values < 0.05 were considered statistically significant and included in the final logistic regression model.

Table 7.

Final logistic regression model.

Covariates	Regression coefficient	Standard error	OR (95% CI)^a	P-value
Female gender (x₁)	0.913	0.582	2.493 (0.80–7.80)	0.366
Age ≤45 years (x₂)	1.093	0.536	3.000 (1.04–8.54)	0.041^b
Surgical time >4 h (x₃)	1.320	0.564	3.744 (1.24–11.33)	0.019^b
Intercept	−3.052
Model X ² (df = 7)^c	11.600
−2Log likelihood	89.057

Odds ratio (OR) for covariates and 95% confidence interval (CI).

P-values < 0.05 were considered statistically significant.

P = 0.008.

Discussion

The point prevalence of immediate post-craniotomy headache ranged from 14.1% to 29.2%. These data differ from the results of the IHS, in which 80% of the patients had headaches (4) and 40% (14) of patients who underwent craniotomy had a headache in the first 24 hours. These differences in headache prevalence may be due to our patients receiving 10 mg of morphine and scalp block during the perioperative period. The use of these medications may have contributed to the reduction in headache occurrence during the post-operative period.

The scalp nerve block by infiltration of anaesthetics decreases the persistence of post-operative pain and allows the early recovery of neurosurgical patients (15). Other studies have shown that the infiltration of the scalp with anaesthetics, associated with the use of dipyrone during the post-operative period, decreased the intensity of pain in the first 12 hours post-surgery, contributing to the well-being and haemodynamic stability of patients and thereby allowing an early hospital discharge (16,17).

Data from this research show that 80% of patients had severe headache in the preoperative period. Although the great majority of patients presented with severe headache in the preoperative period, none of the patients used strong opioids for pain control. Opioid analgesics are the main intervention for pain control in hospitalised patients, especially for moderate to intense pain (18).

Severe pain is common in hospitalised patients, who may suffer unnecessarily due to delays in the administration of analgesics that are not always effective (19). Untreated acute pain causes neurovegetative changes, worsening clinical signs and physical and psychological suffering in patients.

A proportion of patients had a moderate intensity headache. Our data are in agreement with a previous study (15), in which the surgical approach was supratentorial and patients also complained of post-surgical headache. After completion of the craniotomy, the presence of headache that follows both surgical manipulation and meningeal irritation is common. ‘The post-surgical intracranial pain is often intense, unassessed and not appropriately treated’ (20,21).

The majority of the patients in this study were admitted to the ICU. Patients hospitalised in this sector are often suffering from pain and another severe symptom (22). After completion of the craniotomy, patients were transferred to the ICU to stabilise their haemodynamic status. As there are health professionals on continuous shifts in the ICU, it should be an optimal environment to adequately treat pain; however, this did not always occur, possibly due to a view that the higher pain scores occurred in the first post-surgery days.

Data from this survey indicate that there were few pain complaint registries in the records of patients. The under-reporting of pain via registration in the patient's medical records may reflect the care provided to patients undergoing craniotomy. This pain needs to be recorded in a systematic manner in order to be adequately treated. Adequate pain evaluation and management should be viewed as inalienable patient rights; however, the findings of this study show that pain management may be suboptimal given that on the seventh day after surgery some patients still had a headache.

A total of 30% of patients did not receive any type of analgesic medication, although they complained of a headache. The use of analgesia in the post-operative period of craniotomy remains a concern and there is controversy between neurosurgeons. Despite the effectiveness of opioids in reducing post-operative pain, many surgeons are still reluctant to prescribe these medicines. This may be driven by a concern that opioid effects will mask the signs of intracranial complications and by a pre-established bias that the pain after craniotomy is minimal (20). Other studies have shown, in contrast with the present study, that until the seventh post-surgical day, some of the patients complained of headache (20).

The therapeutic success for pain control is based on the correlation between the pain mechanism and the effect of the drug used; however, our data contradict the World Health Organization (WHO, which advocates (23) the use of an analgesic ladder for the choice of an appropriate therapeutic treatment. The WHO analgesic ladder indicates the use of weak and strong opioids to treat moderate and strong pain intensity, respectively; opioids are used in conjunction with non-opioid analgesics or NSAIDS and adjuvant drugs in the former.

We noted a statistically significant difference between the first and second assessment of headache. Conversely, there was no statistically significant difference in further reassessments. These data suggest that, although analgesics decreased pain intensity, they were not sufficient for complete headache relief. It is important to highlight that there was also pain reduction in the group of patients who did not use analgesics. The possible explanation for the pain persisting in the group of patients treated with analgesics was related to the medical diagnosis before the surgery and the duration of the operation being >4 hours. The low use of opioids for moderate pain may also have contributed to the persistence of the painful phenomenon in this group of patients.

The lack of strong opioid prescriptions for pain relief may have contributed to headache persistence in these groups of patients. Among the opioids, morphine is considered the standard medication for the treatment of acute and chronic pain. This is because morphine has a high efficacy for the treatment of moderate and intense pain and, unlike NSAIDS and mixed opioids, it does not have a dosage ceiling (24,25).

In the post-craniotomy period, headache may become a problem when not appropriately treated and systematised by the multi-disciplinary team. Health professionals must consider that pain is an experience that is unique to each person and that to assess and treat a patient's pain assistance should be based on scientific principles, technical training and attitude, which are the three forming competence factors.

To reduce post-craniotomy headache intensity, health professionals need to be aware of the importance of proper pain management, multi-disciplinary team participation, analgesia protocols, specialised teams and the creation of services for acute pain with appropriate quality assistance. Although pain is considered as the fifth vital sign, there are still health professionals who do not value the pain process assessment and, consequently, inadequate pain treatment continues to be a clinical problem in hospitalised patients (19,26,27).

The final logistic regression model indicated that an age of <45 years was associated with the occurrence of headache in the post-operative period. Individuals with advanced age are thought to experience lower pain intensity than young adults due to neurobiological alteration of nociceptors that occurs with the ageing process. The changes that occur in pain perception in elderly people are not clearly elucidated, but a nociception model in animals has shown, via electrical stimulation of repetitive afferent fibres, that the receiving properties of afferent terminals and conduction membranes of the axon are altered with age, suggesting that the elderly feel less pain than young adults (28).

Multiple logistic regression also indicated that a surgery time of >4 hours increases the likelihood of post-surgical headache. Post-operative pain, in general, is almost always proportional to the degree of stimulation of free nerve endings, the surgical incision, tissue trauma and surgical duration. Hence, there appears to be greater tissue injury with increases in the duration of surgery (29,30).

A limitation of our study is that patients were not specifically assessed for a history of pre-existing primary headache, which has been recognised as a risk factor both for brain tumour-associated headache and for post-craniotomy headache (31,32).

We conclude that a proportion of patients who underwent elective craniotomy had a headache, but this was of moderate intensity for the majority of patients. Furthermore, the pain was under-reported in the patient's medical records. The analgesia used in the post-operative period was not sufficient for pain relief. Health professionals should pay particular attention to patients aged <45 years and whose surgery lasts >4 hours, as these patients are more likely to have painful post-craniotomy headaches. These data highlight the need for investment in the training of professionals who assist patients undergoing craniotomy and the need to create protocols for analgesia and systematic pain assessment.

Footnotes

Clinical implications

Further training should be provided to professionals caring for patients undergoing craniotomy to better manage post-operative headache.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sector.

Conflict of interest

None declared.

References

De Gray

Matta

. Acute and chronic pain following craniotomy: A review. Anesthesia 2005; 60: 693–704.

Bonica

. Anatomic and physiologic basis of nociception and pain. In: (Bonica JJ ed.) The management of pain, 2nd edn. Philadelphia, PA: Lea & Febiger, 199028–94.

Rocha-Filho

PAS

Gherpelli

de Siqueira

. Post-craniotomy headache: A proposed revision of HIS diagnostic criteria. Cephalalgia 2010; 30: 560–566.

Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders, 2nd edn. Cephalalgia 2004; 24(Suppl. 1): 9–160.

Hassouneh

Centofanti

Reddy

. Pain management post-craniotomy patients: A survey of Canadian neurosurgeons. Can J Neurol Sci 2011; 38: 456–460.

De Benedittis

Migliore

Lorenzetti

. Postoperative pain in neurosurgery: A pilot study in brain surgery. Neurosurgery 1996; 38: 466–470.

Ferreira

Dach

Speciali

. Scar neuromas as triggers for headache after craniotomy: Clinical evidence. Arq Neuropsiquiatr 2012; 70: 206–209.

De Gray

Matta

. Acute and chronic pain following craniotomy: A review. Anesthesia 2005; 60: 693–704.

Filatova

Latysheva

Jurenkov

. Evidence of persistent central sensitization in chronic headaches: A multi-method study. J Headache Pain 2008; 9: 295–300.

10.

Harner

Beatty

Ebersold

. Headache after acoustic neuroma excision. Am J Otol 1993; 14: 552–555.

11.

International Association for Study of Pain (IASP). Consensus development conference statement: The integrated approach to the management of pain. Accid Emerg Med 1994; 6: (document number 491–292).

12.

Sudheer

Logan

Terblanche

. Comparison of the analgesic efficacy and respiratory effects of morphine, tramadol and codeine after craniotomy. Anesthesia 2007; 62: 555–560.

13.

Hosmer

Lemeshow

. Applied logistic regression, 2nd edn, chapter 4.3. New York: John Wiley & Son, 2000369–512.

14.

Rocha-Filho

PAS

Gherpelli

de Siqueira

. Postcraniotomy headache: Characteristics, behaviour and effect on quality of life in patients operated for treatment of supratentorial intracranial aneurysms. Cephalalgia 2008; 28: 41–48.

15.

Batoz

Verdonck

Pellerin

. The analgesic properties of scalp infiltrations with ropivacaine after intracranial tumoral resection. Anesth Analg 2009; 109: 240–244.

16.

Grossman

Ram

Perel

. Control of postoperative after awake craniotomy with local intradermal analgesia and metamizol. IMAJ 2007; 9: 380–382.

17.

Blanshard

Chung

Manninen

. Awake craniotomy for removal of intracranial tumor: Considerations for early discharge. Anesth Analg 2001; 92: 89–94.

18.

Jarzyna

Jungquist

Pasero

. American society for management nursing guidelines on monitoring for opiod-induced sedation and respiratory depression. Pain Manag Nurs 2011; 12: 118–145.

19.

Maier

Nestler

Richter

. The quality of pain management in German hospitals. Dtsch Arztebl Int 2010; 107: 607–614.

20.

Gottschalk

Yaster

. The perioperative management of pain from intracranial surgery. Neurocrit Care 2009; 10: 387–402.

21.

Teo

Eljamel

. Craniotomy repair reduces headaches after retrosigmoid approach. Neurosurgery 2010; 67: 1286–1291.

22.

Helms

Barone

. Physiology and treatment of pain. Crit Care Nurse 2008; 18: 38–49.

23.

World Health Organization. Cancer pain relief. With a guide to opioid availability, Geneva: WHO, 1996.

24.

Aubrun

Valade

Coriat

. Predictive factors of severe postoperative pain in the postanesthesia care unit. Anesth Analg 2008; 106: 1535–1541.

25.

Hansen

Brennum

Moltke

. Pain treatment after craniotomy: Where is the (procedure-specific) evidence? A qualitative systematic review. Eur J Anaesthesiol 2011; 28: 821–829.

26.

Allegri

. Postoperative pain in Italy: An update. Minerva Anestesiol 2009; 75: 604–604.

27.

Duingnan

Dunn

. Perceived barriers to pain management. Emerg Nurs 2009; 16: 31–35.

28.

Taguchi

Ota

Matsuda

. Cutaneous C-fiber nociceptor responses and nociceptive behaviors in aged Sprague-Dawley rats. Pain 2010; 151: 771–782.

29.

Fok AWM and Yau WP. Delay in ACL reconstruction is associated with more severe and painful meniscal and chondral injuries. Knee Surg Sports Traumatol Arthrosc. Epub ahead of print 3 May 2012. DOI: 10.1007/s00167-012-2027-1.

30.

Mueller

Tinguely

Tevaearai

. Pain location, distribution, and intensity after cardiac surgery. Chest 2000; 118: 391–396.

31.

Schankin

Ferrari

Reinisch

. Characteristics of brain tumour-associated headache. Cephalalgia 2007; 27: 904–911.

32.

Schankin

Gall

Straube

. Headache syndromes after acoustic neuroma surgery and their implications for quality of life. Cephalalgia 2009; 29: 760–771.

Immediate post-craniotomy headache

Abstract

Introduction

Objectives

Methods

Results

Conclusion

Keywords

Introduction

Methods

Study design

Participants

Variables

Diagnosis of immediate post-craniotomy headache

Setting

Assessment of analgesic consumption

Statistical methods

Results

Preoperative pain

Prevalence of immediate post-craniotomy headache and pain registration

Post-surgery analgesic consumption

Univariate and multiple logistic regression analysis

Discussion

Footnotes

Clinical implications

Funding

Conflict of interest

References