Objectives: Our aim is to compare skull block using 0.5% bupivacaine versus the use of intravenous fentanyl during the maintenance phase of general anesthesia for supratentorial craniotomies in geriatric patients as regarding hemodynamic stability, effect on intracranial pressure (ICP), effect on plasma cortisol level as a part of surgical stress response, recovery time and postoperative pain scores.Patients & Methods: Eighty patients were enrolled in the study. There were 43 male and 37 female patients with a mean age of 70.15±2.11 years (ASA I, II, III) undergoing elective supratentorial craniotomy. After induction of general anesthesia (GA), patients were randomly assigned into two equal groups: Group B: patients had skull block using bupivacaine (0.5%) and epinephrine (1:400,000); Group F: patients received fentanyl 2 µg/kg (during maintenance of GA). Heart rate (HR) and mean arterial pressure (MAP) and plasma cortisol level were recorded at baseline (before induction of anesthesia) , 1 minutes after intubation, 1 minute after skin incision, 1 minutes after dural incision, 1 minute after dural closure, 1 minute after skin closure, 1 minute after extubation. ICP was measured at the above-mentioned time points except at dura where ICP measured before dural incision. Time to recovery from anesthesia was also recorded. Visual analogue scale (VAS) was recorded every hour for the first 4 hours postoperatively.Results: MAP, HR, plasma cortisol level showed significant differences between-groups, where group F had higher MAP, HR and plasma cortisol level than group B. Group B had rapid recovery period and less postoperative pain scores than group F.Conclusion: Scalp Blockade of the nerves that supply the involved region of the scalp may be an effective, alternative technique to the usage of opioids in geriatric patients resulting in maintaining hemodynamic stability, reducing neuro-endocrinal stress (plasma cortisol level), decreasing the requirement for vasodilators and the requirement for increasing depth of anesthesia during the surgical procedure resulting in rapid recovery period, and decreasing postoperative pain scores.