Symptom-Based Opioid-Free Treatment for Persistent Postoperative Headache After Vestibular Schwannoma Resection via the Retrosigmoid Approach

Objective Postoperative headache (POH) is a disturbing symptom following vestibular schwannoma (VS) resection. However, there are currently no treatment guidelines. The aim of this study was to evaluate the usefulness of symptom-based opioid-free treatments for persistent POH following VS resection. Methods Of 137 patients in whom sporadic VS was resected via the retrosigmoid approach, 74 had persistent POH beyond 3 postoperative months. Their symptoms were classified as tension-type headache, migraine, neuralgia, or other and were treated. We retrospectively analyzed the treatment outcomes during 2 postoperative years. Results Patients with persistent POH were significantly younger (P = 0.003) and had significantly smaller tumors (P = 0.001) and greater extent of resection (P = 0.04) than patients without POH. The most common simple symptom was tension-type headache in 56 patients, followed by migraine in 6 patients and neuralgia in 5 patients. All 7 patients with complex symptoms had a mixture of tension-type headache and migraine. Complete disappearance of POH was achieved in 40 (54%) patients, and a medication-free condition was achieved in 51 (69%). No patients had residual severe POH that could not be controlled with medication. Achievement of a medication-free outcome that included complete disappearance of persistent POH was significantly more common in patients with preserved facial nerve function (P = 0.008) and patients with simple symptoms (P < 0.001). Conclusions A symptom-based approach is appropriate for understanding and managing persistent POH after VS resection with excellent pain control. Preserved facial nerve function and simple symptoms are significant prognostic factors for a medication-free outcome.