The aim of this study is to evaluate the effects of intravenous fentanyl and local lidocaine infiltration on the haemodynamic response to Mayfield skull pin head holder (MH) placement. Forty-five patients scheduled for elective craniotomy were studied. They were randomly divided into three groups. Group F received 2 μg/kg-1 fentanyl i.v. 5 min before placement of the MH, group L was administered 3 ml 1% plain lidocaine by infiltration at each pin site 1 minute later and before placement of the MH, and both methods were applied together in group FL. Mean arterial blood pressure (MAP) and heart rate (HR) were recorded at 5 preset times. Both were significantly increased during and after MH placement in group F compared to groups L and FL. In group L, there was a significant increase in MAP and HR during the placement of MH compared to group FL. In group FL, there was no significant increase in MAP or HR at any time of the recordings. We conclude that intravenous fentanyl with local infiltration of lidocaine into the periosteum is effective in reducing the haemodynamic response to MH placement in patients undergoing craniotomy.