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Changes in headache could signal brain tumor.

SCOTTSDALE, ARIZ. -- "Red flag" characteristics can help in the diagnosis of brain tumor in patients with headache, Dr. R. Allan Purdy said at a symposium sponsored by the American Headache Society.

Headache is the most common general symptom of brain tumor, but in a prospective study of 183 adult patients, almost all had at least one other neurologic symptom; only 8% had headache as the sole symptom. The longest time any patient had headache without other symptoms was 77 days. Thus "patients with chronic headache for months or years without any other major new symptoms probably do not have a brain tumor," said Dr. Purdy of the Queen Elizabeth II Health Sciences Center, New Halifax, N.S.

Other red flags that should prompt evaluation for brain tumor or other serious or life-threatening causes of headache include:

* Acute new (usually severe) headache, or headache that has changed from prior headaches.

* Headache on exertion.

* Headache onset at night or in the early morning.

* Headache that is progressive in nature.

* Headache that is associated with fever or other systemic symptoms.

* Headache with meningism.

* Headache with new neurologic signs.

* Precipitation of head pain with the Val-salva maneuver (by coughing, sneezing, or bending down).

* Headache in the elderly or children.

Older patients with new-onset headache should be regarded with particular concern. As many as 15% of patients age 65 or over who present to neurologists with new-onset headache are found to have serious pathologies. "New-onset headache in a patient over 50 should invoke consideration of secondary headache disorder requiring specific diagnostic testing," he said.

It is vital to consider other serious etiologies beyond primary headache disorder or neoplasm, Dr. Purdy stressed. Other possible causes include systemic infection (meningitis, encephalitis), stroke, subarachnoid hemorrhage, systemic disorders (thyroid disease, hypertension, pheochromocytoma), temporal arteritis, traumatic head injury, or serious ophthalmologic and otolaryngologic causes.

In a retrospective review that was conducted by P.A. Forsyth and J.B. Posner, most brain tumor headaches (77%) met criteria for tension-like headache, 9% were migraine-like, and the remaining 14% were mixed (Neurology 43[9]:1678-83, 1993).

Recent studies show that headache is present in 37%-62% of patients presenting with neoplasms. Patients with raised intracranial pressure, larger tumors with more midline shift on imaging studies, and those with a previous history of headache are more likely to present with headache. Headaches also are more common in patients with posterior fossa lesions (which can raise intracranial pressure) and faster growing tumors, and less common in slower growing meningiomas and low-grade gliomas, Dr. Purdy noted.

Location of pain is not considered useful in distinguishing tumor headache from nontumor headache. The increased intracranial pressure caused by neoplasm can cause the patient's headache to be generalized.

Brain tumors are believed to cause headaches as a result of traction on the large blood vessels and dura, as well as direct pressure on cranial and cervical nerve fibers by tumor, Dr. Purdy explained.

Less common headaches associated with brain tumors include cough headache, paroxysmal headaches, and cluster-like headache reported in brain neoplasms such as prolactinoma and lung metastases. "Neurologists should exercise caution in making these unusual primary headache diagnoses and be certain to rule out secondary etiologies," Dr. Purdy said.


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Title Annotation:Pain Medicine
Author:Melville, Nancy A.
Publication:Clinical Psychiatry News
Date:Feb 1, 2004
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