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6.5.2 Post-endarterectomy headache


Headache caused by the surgical procedure of carotid endarterectomy. Pain can also involve the neck and face. It can remain isolated or be a warning symptom preceding the focal deficits of (mostly haemorrhagic) stroke.

Diagnostic criteria:
  1. Any new headache fulfilling criterion C
  2. Carotid endarterectomy has been performed
  3. Evidence of causation demonstrated by at least two of the following:
    1. headache develops within 1 week of the carotid endarterectomy
    2. headache resolves within 1 month after the carotid endarterectomy
    3. both of the following:
      • a) headache is unilateral, on the side of the carotid endarterectomy
      • b) headache has one of the following three distinct characteristics1:
        • – diffuse mild pain
        • – cluster headache-like pain occurring once or twice a day in attacks lasting 2-3 hours
        • – pulsating severe pain
  4. Not better accounted for by another ICHD-3 diagnosis2.
  1. Three subforms of 6.5.2 Post-endarterectomy headache have been described, but are not separately coded:
    • a) a diffuse, mild isolated headache occurring in the first few days after surgery;
    • b) a unilateral cluster headache-like pain with attacks, lasting 2-3 hours, occurring once or twice a day;
    • c) unilateral pulsating and severe pain occurring 3 days after surgery.
  2. In particular, arterial dissection has been excluded by appropriate investigations.

Of the three subforms of 6.5.2 Post-endarterectomy headache, the first and most frequent (up to 60% of cases) is a benign self-limiting condition while the second (reported in up to 38% of cases) resolves in about 2 weeks. The third subform is part of the rare hyperperfusion syndrome, often preceding a rise in blood pressure and the onset of seizures or neurological deficits on or about the 7th day. Urgent treatment is required, since these symptoms can herald cerebral haemorrhage.