Objective Headache after decompressive craniectomy and subsequent cranioplasty remains insufficiently characterized, particularly with respect to postoperative neuralgiform pain topography. We prospectively evaluated a two-year cranioplasty cohort to characterize secondary postoperative headache syndromes and to identify clinically recognizable topographic patterns of neuralgiform cranial pain. Methods We conducted a prospective observational study of 84 consecutive patients who underwent cranioplasty after prior decompressive craniectomy during a two-year period at a tertiary neurosurgical center. All patients constituted the source cohort. A predefined high-disability subgroup with modified Rankin Scale score > 3 was used for detailed phenotype extraction and descriptive analysis. Because headache is a subjective symptom and neurological disability may affect symptom perception, communication, and documentation, headache frequencies derived from this subgroup were interpreted as descriptive and hypothesis-generating rather than as unbiased population-level incidence estimates. Available preoperative records were reviewed for pre-existing migraine, trigeminal neuralgia, chronic headache, or facial pain. Results Among 84 cranioplasty patients, 34 met the predefined high-disability threshold. Within this subgroup, 22 patients had documented clinically meaningful postoperative secondary headaches, corresponding to 26.2% of the full source cohort and 64.7% of the enriched subgroup. These proportions should be interpreted as documented frequencies within a clinically selected subgroup rather than as generalizable incidence rates. Detailed free-text review showed that these cases were better classified within post-traumatic and persistent post-craniotomy/post-craniectomy headache frameworks than as a single uniform syndrome. Among 12 cases with sufficiently localizable neuralgiform topography, 8 were occipital-predominant and 4 were supraorbital/frontal-predominant. The remaining cases were diffuse, mixed, facial-trigeminal, or insufficiently localized for reliable anatomic subclassification. Conclusions Postoperative headache after decompressive craniectomy and cranioplasty appears to represent a heterogeneous spectrum of secondary postoperative headache syndromes rather than a single distinct entity. Within this spectrum, a neuralgiform subgroup can be identified, most commonly with occipital predominance and less often with supraorbital/frontal localization. These findings support more systematic postoperative pain phenotyping and may guide anatomically targeted evaluation and management, while requiring validation in larger cohorts using standardized headache instruments.
Shemesh et al. (Mon,) studied this question.