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Headaches in chronic subdural hematoma: Does size matter?
Crystal X Wang1, James Feghali1, Jiwon Moon1
1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Insights
Headache in chronic subdural hematoma (cSDH) is linked to larger hematoma thickness. A threshold of 12.5 mm hematoma thickness may indicate headache development in cSDH patients.
Area of Science:
- Neurosurgery
- Neurology
- Radiology
Background:
- Chronic subdural hematoma (cSDH) commonly causes headaches, but the exact relationship between hematoma size and headache severity is not fully understood.
- Understanding this relationship is crucial for diagnosing and managing cSDH patients effectively.
Purpose of the Study:
- To investigate the association between total hematoma size and headache presentation in patients with cSDH.
- To identify a critical hematoma thickness threshold for the development of headaches in cSDH.
Main Methods:
- Retrospective review of adult cSDH patients diagnosed between January 2023 and June 2025.
- Exclusion of patients with Glasgow Coma Score (GCS) < 14 or history of ventricular shunt.
- Analysis of demographic data, hematoma characteristics, headache presence, and GCS using logistic regression and ROC analysis to determine the relationship between hematoma thickness and headache.
Main Results:
- Out of 341 eligible patients, 49.6% presented with headache.
- Patients with headache exhibited significantly greater hematoma thickness (18.3 mm vs. 15.1 mm) and more frequent midline shift.
- Younger age and increased hematoma thickness were independently associated with headache (OR=1.03, p=0.029).
- A hematoma thickness threshold of 12.5 mm was identified for headache development (AUC=0.596, p=0.002).
Conclusions:
- Headache in cSDH is multifactorial, with younger age and greater hematoma thickness being independent predictors.
- A critical hematoma thickness of 12.5 mm may serve as a threshold for clinically apparent headaches due to stretching of pain-sensitive structures.
Objectives:
Chronic subdural hematoma (cSDH) frequently presents with headache, but the relationship between hematoma size and headache is not well defined. This study aims to determine the relationship between total hematoma size and headache presentation in cSDH patients while identifying a critical size threshold for headache development.
Methods:
We retrospectively reviewed adult cSDH patients diagnosed at our institution from January 1st, 2023, to June 4th, 2025. Patients with a Glasgow Coma Score (GCS) below 14 or a history of ventricular shunt were excluded. Data collected included demographic information, hematoma laterality, maximum cSDH diameter, headache on presentation, and GCS. Hematoma thickness was defined as the sum of maximum cSDH diameter on both sides. Multivariable logistic regression and receiver operating characteristic (ROC) analysis were performed to assess the association between headache presentation and hematoma thickness.
Results:
Among 341 eligible patients, 169 (49.6 %) presented with headache. Patients with headache had greater hematoma thickness (18.3 ± 10.7 mm vs. 15.1 ± 9.8 mm, p = 0.004) and more frequent midline shift (49 % vs. 32 %, p = 0.002). Multivariable analysis showed younger age (OR = 0.97; 95 %CI 0.95-0.99; p = 0.001) and larger hematoma thickness (OR = 1.03; 95 %CI 1.01-1.05; p = 0.029) were independently associated with headache. ROC analysis identified a hematoma thickness threshold of 12.5 mm (AUC = 0.596; 95 %CI 0.536-0.656, p = 0.002).
Conclusion:
Younger age and larger hematoma thickness were independently associated with headache in patients with cSDH, which is multifactorial. A critical hematoma size threshold of 12.5 mm was derived for headache development, beyond which stretching of pain-sensitive structures may become clinically apparent.
