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Is This A Brain Tumor That Hurts?

Alicia R. Prestegaard, M.D. answers frequently asked questions regarding the relationship between headaches and brain tumors.

Are headache and brain tumors related?

Headache is a common symptom that may occur in otherwise healthy individuals. Typically, physicians are not concerned if the headache is occasional, mild, of short duration, and caused by identifiable factors (e.g., flu-like illness, sinus infection, fasting, sleep deprivation, or alcohol-induced "hangover"). However, patients who experience frequent or severe headache often worry about the possibility of a more serious underlying condition such as a life-threatening brain tumor.

Though very rare in the total population of patients with recurring headaches, approximately 50% of patients who do have brain tumors have a headache as a presenting complaint, and up to 60% of patients develop headaches as the disease progresses. Unfortunately, it is often impossible to diagnose a brain tumor based upon the description of the headache itself. Some patients do provide clues when presenting with seizures or persistent neurological symptoms.

What symptoms differentiate a brain tumor from other headaches?

Typical brain tumor headaches are "tension-like," aching in nature, and can occur intermittently with a gradual onset and resolution over a few hours. The headache can also be throbbing, resembling common migraine. There have been reports in the literature of patients whose brain tumors presented with classical migraine-like headache with aura which progressively worsened over a few months. Tumors can also obstruct cerebrospinal fluid flow which can cause headaches. These events can even be accompanied by loss of consciousness or loss of muscle tone.

In a patient with a normal neurological exam and no other complaints, the sole symptom of headache is rarely related to a brain tumor. Certain specific features of headache have been identified as "red flags," which may suggest the presence of a structural abnormality (lesion), such as a brain tumor.

These red flags may include: a change in previous headache pattern; headache unresponsive to therapy; any new motor (weakness), sensory, or visual symptoms or signs; a change in memory, personality, or thinking; prolonged/repetitious vomiting; or a headache getting worse when bending over, coughing, sneezing, or Valsalva maneuver. These symptoms can frequently occur in benign headaches as well.

Smokers or patients with a history of cancer, including lung, breast, prostate, or neck cancer, are at increased risk of metastatic spread of the tumor to the brain. Since pediatric tumors are typically located in the brainstem (lower portion) of the brain, they commonly induce specific symptoms, which physicians identify with careful history taking and examinations. Adults as well as children must undergo proper evaluation by an experienced physician, often a neurologist, and testing, usually with an MRI, is necessary.

How are brain tumors diagnosed?

Quite often it is not a headache that leads to the diagnosis of a brain tumor. Depending on the location of the tumor, it may take months or even years for the lesion to increase in size sufficiently to produce symptoms. Some tumors are discovered accidentally, such as during routine screening for migraines or following a minor head trauma, though this is very uncommon.

Frequently patients with brain tumors seek evaluation by a physician because of other symptoms. For example, they may suddenly or gradually develop visual disturbances, weakness on one side of their body, slurred speech, hearing loss, ringing in the ears, imbalance, dizziness, memory and/or cognitive problems, seizures, or even incontinence. An abnormal neurological examination is the most worrisome predictor of structural brain lesion.

What steps does the physician take when a brain tumor is diagnosed?

It is the role of the physician to determine which patients require further testing for potential serious illness. Usually an MRI scan of the head with contrast is the most sensitive and preferable. In some cases additional studies should be ordered, such as a CT scan to look for bony infiltration, or imaging of other parts of the body to determine if a primary tumor may be present. Some patients may require a lumbar puncture (spinal tap) to evaluate the spinal fluid, which can provide a clue to the cause of headaches.

If a tumor is present, the patient will be evaluated by both a neurosurgeon and often an oncologist. The neurologist is frequently involved in management of the patient with brain cancer in terms of monitoring the neurological status and treating complications, such as brain edema, epilepsy, strokes, pain, etc.

Summary

As stated earlier, the occurrence of brain tumors in the headache population is extremely rare. At MHNI it is particularly rare, since by the time most patients reach the Institute, they have been evaluated by many physicians, and the most common headaches treated at MHNI are the primary headaches, such as migraine and related disorders.