Postoperative pain management strategies in brain surgery

The management of postoperative pain after brain surgery is challenging due to the vulnerability of neuroanatomic structures and differences in the perception of pain among different individuals. Pain management is essential for the patient's quick recovery. The main aim of the review is to assess the various pharmacological and non-pharmacological techniques for managing pain in patients after brain surgery, highlighting the potential benefits and safety. This is a focused narrative review of literature published between 2016 and 2024. A targeted search of major databases: PubMed/MEDLINE, EMBASE, Scopus, Web of Science, Cochrane CENTRAL and Google Scholar was performed using terms for postoperative pain, craniotomy, neurosurgery, scalp block, multimodal analgesia, gabapentinoids, dexmedetomidine, cognitive behavioral therapy, Transcutaneous Electrical Nerve Stimulation and related concepts. The present review purposively selected randomized controlled trials, systematic reviews, meta-analyses and high-quality observational studies that evaluated analgesic strategies for major intracranial procedures. Non-English reports, narrative reviews lacking primary data, and studies with inadequate outcome reporting were excluded. Data synthesis is solely narrative and focused on comparative effectiveness and safety. The evidence supports opioid-sparing, multimodal strategies after major intracranial procedures. NSAIDs and acetaminophen show modest reductions in pain up to 12-24 hours. Local anesthetic scalp blocks and wound infiltration such as ropivacaine provide short-term benefit. Gabapentinoids reduce opioid consumption but increase dizziness and somnolence. Dexmedetomidine can delay rescue analgesia intraoperatively but is not consistently superior to alternatives. Non-pharmacologic approaches including, cognitive behavioral therapy, Transcutaneous Electrical Nerve Stimulation, Repetitive transcranial magnetic stimulation or, transcranial magnetic stimulation acupuncture show promise for longer-term or neuropathic symptoms, but evidence is limited and heterogeneous. Multimodal, opioid-sparing regimens, combining systemic non-opioid analgesics, targeted local or regional techniques, and selected adjuvants appear most effective for early postoperative pain after intracranial surgery. Non-pharmacologic therapies and neuromodulation may have adjunctive roles, but higher-quality comparative trials with standardized outcomes are needed to define optimal protocols and long-term effects.