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We review the current known pathophysiology of post-craniotomy headaches and present a hypothesis suggesting a greater recognition of the potential contribution of neuroma formation in areas of scars tissue to contribute to this kind of headache. Key words: post-craniotomy headache, neuromas, nerve block.

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Post-craniotomy headache PCH is a secondary headache that appears as a consequence of neurosurgical interventions requiring craniotomy. It is defined by the current International Classification of Headache Disorders ICHD-II as a headache of variable intensity, most severe near the site of craniotomy motivated by non-traumatic reasons. Its onset happens within 7 days of the surgery 1. When the onset of PCH happens within days of the craniotomy, diagnosis is typically not difficult 7,8. However, when the time elapsed between the craniotomy and headache onset is longer, diagnosis may be difficult and complex 1.

Herein, we report 4 cases of headaches related to neurosurgical incisions that did not fulfill criteria for PCH, with the purpose of gathering and sharing information about this poorly discussed headache type.

Clinical Conditions

This report was approved by the Ethics Committee of our Institution and signed consents were obtained. A year-old woman, with a past history of migraine without aura, had neurosurgery to remove a benign tumor at the age of Duration was up to 12 hours, and response to analgesics was poor. During the headaches, she had nausea and photophobia. She had used amitriptyline, propranolol, chlorpromazine, carbamazepine and topic capsaicine for the treatment of her pain, with little improvement. We repeated the procedure three more times during the next four months. She reported important reduction in the frequency of her headaches, from daily to around once a month.

She has been followed for 7 years, without worsening Table. A year-old woman with a past history of tension-type headache had surgery for aneurism clipping left middle cerebral artery at the age of Pain was throbbing and of short duration, lasting 2 to 3 minutes. Attacks recurred several times each day. Pain was not associated with phonophobia, photophobia or autonomic signs. Previous treatments included the use of amitriptyline and diclofenac, without improvement. At follow-up two months after injection , she reported having experienced only one mild attack.

She has been followed for 2 years, without worsening Figure. A year-old woman had two craniotomies at the age of 30, for surgical clipping of aneurisms in both middle cerebral arteries. She reported having no headaches until the surgery. Pain typically lasted 24 hours and was accompanied by ipsilateral conjuntival injection and lacrimation that persisted throughout the attack. Attacks were aggravated by routine physical activity, but they were not accompanied by agitation, nausea, photophobia or phonophobia.

Frequency was from 3 to 4 times per week, with pain-free intervals lasting more than 24 hours. She reported total improvement of pain and no headache attacks at the follow-up two years after the injections Table. A year-old man had right temporal lobectomy for the treatment of epilepsy at the age of He had no past history of headaches. One month after the procedure, he reported onset of headache attacks right temporal region.

Attacks lasted up to 72 hours and happened once a week.

Amitriptyline had been tried, without improvement. He has been followed for 2 years, without headaches Table. In the currently study, we reported four cases that did not fulfill criteria for PCH headaches appeared after 1 week , but had headaches associated to neurosurgical scars. Case 1 describes a patient with migraine-like headache and substantial increase in the frequency of the headaches five years after the surgical procedure.

Injection on painful sites induced remission. Case 2 describes a patient with episodic tension-type headaches who, 7 years after the craniotomy, developed a different headache syndrome, characterized by frequent, short duration attacks. Cases 3 and 4 describe patients without past history of headaches. After the craniotomy after 1 month in one case and after 9 years in the other , they developed new onset headaches. Headaches had some migrainous characteristics and were associated with autonomics signs ipsilateral to the pain.

In these cases, the time elapsed between the surgical procedures and the development, worsening, or modification of the headaches varied from 30 days to 9 years.

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Headaches were throbbing, severe and worse in proximity to the surgical scars. Duration of attacks varied from a few minutes to 72 hours, and monthly frequency of attacks ranged from 12 to 30 days. Prophylactic use of amitriptyline, propranolol, chlorpromazine, carbamazepine and topic capsaicine resulted in little or no improvement. Despite the long time between surgery and the onset of headache, we consider the causal relation based on: 1. Difficulty in fulfilling the necessary criteria for primary headaches cases 2, 3 and 4 ; 2. Limited response to standard preventive medications cases 1 and 4 ; 3.

Pain happened mainly and was stronger in the region of the craniotomy, being ipsilateral to the surgery all cases ; 4. Pain was invariably triggered by pressing specific points on the surgical scars all cases ; 5. Patients experienced total remission or significant improvement of the headaches after the injection of the previously identified trigger points all cases. The pathophysiology of PCH seems to involve meningeal inflammation 9 , nerve compression, nerve entrapment, muscular and meningeal fibrosis 10 , and central sensitization The role of neuromas as a cause of PCH has been suggested 5.

Neuromas are characterized by abnormal tissue growth regenerating axons surrounded by connective tissue. They typically appear after traumatic injuries, as a consequence of pressure or laceration of the nerves. It is hypothesized that abnormal voltage-dependent Na channels in these neuromas may induce a state of axonal hyperexcitability. Because neuromas have aberrant conductive capacity, abnormal sensorial and nociceptive perception may arise 12, The continuous input generated by these axons would be conducted to the second and third neurons trigeminal nucleus caudalis and thalamus.

This sensitization, induced by neuromas, would contribute to the worsening or change in the pattern of a pre-existing headache, or to the development of a new headache Accordingly, the role of neuromas in both initiation and maintenance of pain has been recognized in other pain disorders such as complex regional pain syndrome 18, Based on lessons learned with these four cases, we emphasize three points.

First, from a temporal perspective, despite the relation between neurosurgical scars and headaches, it is impossible to classify our cases as PCH as per the ICHD-II A second consideration regards the pathophysiology of these headaches. This means you may need to start wearing maternity clothes. Your breasts may not be as tender as they were in the first trimester, but they will continue to grow. Enlarging milk glands and deposits of fat cause the growth.

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These changes prepare you for breastfeeding. You may notice that the skin on and around your nipples darkens. You may also have small bumps around your nipples. The bumps are glands that make an oily substance to keep your nipples from drying out. A yellowish fluid, called colostrum, might begin to leak from your nipples. As your body grows, some areas of skin may become stretched tight.

Elastic fibers right beneath the skin may tear. This creates streaks of indented skin called stretch marks. Stretch marks are likely to occur on your belly and breasts. Not every pregnant woman gets stretch marks, but they are very common. Unfortunately, there is no way to prevent them completely.

Try to manage your weight and not gain more than what your doctor recommends. There are some lotions and oils that claim to prevent stretch marks. The effects of these products are not proven. However, keeping your skin well moisturized can help cut down on itchiness. Stretch marks should fade and become less noticeable after pregnancy. Not all pregnant women have skin changes. Most often, these changes may lessen or go away after pregnancy. Common skin changes include:.

Leg pain. You may have leg cramps, especially when you sleep.

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  • Make sure you sleep on your side instead of your back. Contact your doctor right away if you have these symptoms. Your ankles, hands, and face may swell during the second trimester. This happens because your body retains more fluid for the baby. You also have slower blood circulation. Your hips and pelvis may begin to ache as pregnancy hormones relax the ligaments that hold your bones together.

    Your bones move to prepare for childbirth. Stomach pain. These can cause mild pain or cramping. Loose teeth. Pregnancy hormones also affect the ligaments and bones in your mouth, so teeth may loosen. They return to normal after pregnancy. Contact your dentist if you have bleeding or swelling of your gums.

    These symptoms can be signs of periodontal disease. This condition has been linked to preterm early birth and low birth weight. The second trimester is the best time to have dental work done. Nasal congestion, nosebleeds , and bleeding gums.

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    These result from increased blood flow to the mucous membranes in your nose and mouth. Heartburn may begin or worsen in the second trimester. Your growing uterus presses on your stomach, which can force food and acid up into your esophagus, causing the burn. Urinary tract infections UTIs.

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    • Symptoms include needing to urinate more often, a burning sensation when you urinate, or the presence of blood or a strong odor in your urine. Braxton Hicks contractions. Braxton Hicks make your belly feel very tight and hard, and may cause discomfort. The contractions are irregular in timing and should go away within a few minutes.

      It might be preterm labor. Near the middle of your second trimester, you may begin to feel the baby.