Elsevier

Neurologic Clinics

Volume 22, Issue 1, February 2004, Pages 39-53
Neurologic Clinics

Review article
Headaches and brain tumors

https://doi.org/10.1016/S0733-8619(03)00099-9Get rights and content

Section snippets

Some historical ideas on brain tumors and headache

The uneasy relationship between headache and brain tumors has been known for more than a century. Gowers wrote of brain tumors [6], “Of the general symptoms, headache is the most constant, absent only in rare cases.” Cushing wrote of his general experience with brain tumors [7], “some degree of headache…is usual.”

Kunkle et al [8] stated, “Headache of patients with brain tumor has been considered to be of limited clinical interest. The mechanism of production has been incompletely understood and

Diagnosing serious headaches including brain tumor

Red flags are as useful today as they always have been in neurologic diagnosis [9], so it bears repeating that any patient who has the following red flags needs evaluation for serious or life-threatening causes of headache, including a brain tumor:

  • Acute new, usually severe, headache or headache that has changed from prior headaches

  • Headache on exertion, onset at night or early morning

  • Headache that is progressive in nature

  • Headache associated with fever or other systemic symptoms

  • Headache with

Case I

This 46-year-old male had an 8-year history of intermittent episodes of neurologic dysfunction. These episodes started with a metallic taste in the mouth for 20 to30 minutes. Then he developed visual disturbance as if he were looking through water, and with this he had tingling of his left hand and tongue. These resolved, or if the episode persisted for 15 minutes, he developed tingling of his left leg. On two occasions, he had slurred speech in addition. Sometimes he was nauseated. All

Case I comment

Migraine has many mimics, including TIA and seizure, and even Gowers noted the latter could occur in close association with seizures—he called it “migralepsy” [10]. Of course a seizure, such as headache, is a symptom, not a disease. In this case, these episodes, although fulfilling some of the IHS criteria for migraine [5], are the result of seizure phenomena resulting from a tumor [11]. The important features in this case were the late-life onset without prior history of migraine, the absence

Brain tumors presenting as headache

Headache may be the first symptom of a brain tumor, yet many patients who present with tumors do not have headache. Kunkle et al [8] found headache was the first symptom in 37% of patients who had supratentorial tumors and in 56% of patients who had infratentorial tumors. Only 25% of Rushton and Rooke's patients [13] reported headache as an initial symptom. More recent studies have demonstrated headache in 37% to 62% of patients presenting with brain neoplasms [4], [14], [15], [16]. Most

Mechanisms of headache in tumors

The mechanism of pain in patients who have brain tumors is presumed to be the result of traction on the large blood vessels and dura and direct pressure on cranial and cervical nerve fibers by tumor [19], [20], [21]. Ray and Wolff [20] mapped pain-sensitive structures in the head through a classic series of experiments on patients undergoing craniotomies. They found that the venous sinuses, some of the dura at the base of the brain, the dural arteries, and the cerebral arteries at the base of

Tumor pathology and headache

Tumor pathology may influence the prevalence of headaches. Slower growing meningiomas and low-grade gliomas may be less likely to cause headache [8], [18]. Slow growing tumors, however, such as low-grade astrocytomas and gangliogliomas [4], may present with seizures before headaches develop. Tumors associated with a posterior fossa lesion, such as medulloblastoma and ependymoma, cause headache in 60% to 83% of patients [8], [18], [24], although a study of brainstem gliomas, excluding

Uncommon headaches in tumor patients

Cough headache has been associated with brain tumors for some time [30]. Patients who have cough headache have severe headache when coughing, sneezing, straining at stool, laughing, or stooping or with any action that produces a Valsalva maneuver. Posterior fossa meningioma, cyst of the midbrain, and (in one case) removal of an acoustic neuroma have been described [30] as causing cough headache. Other cerebral neoplasms also can mimic benign exertional headache [31].

Paroxysmal headaches can be

Case II

This 46-year-old woman had a lifelong history of headache, worse at the time of her menses. They usually were unilateral, on the right, worse with activity, and better with rest. They lasted the better part of a day. She was bothered by lights, sounds, and occasionally smells. She rarely had an aura with her headaches and they responded to simple analgesics and bed rest.

In September 2002 she presented to her local hospital with a severe exacerbation of her headache, localized in the right

Case II comment

This second case again illustrates the need to beware of the changing headache even in patients who have typical migraine with aura. The salient points in this case are the prolonged “symptoms,” the evolution of hallucinosis, and the localized pain with movement. Any of these in any one case or attack may not be significant but in this patient the changes were relevant, despite her headaches continuing to be paroxysmal and her examination remaining normal. Furthermore, white matter lesions in

Investigation of headache patients who have suspected tumor

Many patients are imaged in order to look for an elusive tumor, which is rarely present if patients had a normal examination [45] or if their presentation was one of a recurrent primary headache disorder, such as migraine headache [46] or typical cluster headache [47].

New-onset headache in a patient over age 50, however, should invoke consideration of secondary headache disorder requiring specific diagnostic testing. As many as 15% of patients age 65 or over who present to neurologists with

Treatment of headache patients who have brain tumor(s)

Treatment of headache associated with brain tumor depends on the type of tumor, the patient's functional status, and stage of the disease. Patients who have metastatic brain tumors have a limited life expectancy and treatment is palliative. Corticosteroids, such as dexamethasone, often provide dramatic relief of headache and other symptoms caused by cerebral edema, although steroid myopathies, sleep disturbance, and mood changes may be troublesome.

Whole-brain radiotherapy often effectively

Headaches as a complication of treatment of brain tumors

Patients who have received radiotherapy for treatment of their tumors may develop headache from treatment [54]. Acute radiation encephalopathy presents within 2 weeks of the onset of radiation with new or worsening headache, focal neurologic symptoms and signs, and nausea and vomiting. Corticosteroids usually alleviate symptoms. Subacute (early delayed) radiation encephalopathy can present between 1 and 6 months after completion of radiation with headache, lethargy, and new or worsening

Summary

  • A careful history and physical examination remain the most important aspects of headache assessment, enabling the neurologist to decide if any further studi es are necessary.

  • Only a minority of patients who have headaches have brain tumors; however, recognition of the headaches characteristically associated with tumors is most important.

  • Some locations are more likely to produce headache (eg, a posterior fossa tumor causes headache more often than a supratentorial tumor).

  • Rapidly growing tumors

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      Why does this particular error recur so often? Perhaps some clinicians, overwhelmed by the sheer volume of patients with headache, adopt an apathetic approach,2,4,51 or maybe the diagnostic errors are partially attributable to the insidious presentation of intracranial tumors and other structural diseases2,4,51: many patients with intracranial tumors have an unremarkable presentation2,4,52; a significant percentage of patients with brain tumor present with isolated headache2,4,53; certain tumors mimic particular headache syndromes2,4,54,55; tumor-related headaches often meet the International Headache Society criteria for migraine, tension, or mixed headaches2,4,56; headaches triggered by cough, exertion, and sexual activity are trivialized despite the high association with posterior fossa structural disease2,4,57; and supratentorial tumors may cause headache with psychological symptoms leading to psychiatric referral.2,4,58 More commonly, poorly trained, inexperienced, or hurried neurologists overlook subtle warning signs of a secondary headache, such as the increasing frequency in this case.2,4,5

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