CHAPTER 14 BRAIN TUMOR HEADACHES Ronald Kanner, MD FAAN FACP, Charles E. Argoff, MD 1. What is the classic description of brain tumor headache? Standard texts describe the classic brain tumor headache as a morning headache that may even wake the patient from sleep in the early hours. It improves as the day goes on and characteristically responds to aspirin and steroids. At one point, the “steroid test” was used as a diagnostic tool for brain tumor headaches. A dramatic response to steroid administration strengthened the diagnosis, on the theory that peritumor edema was resolving. Over the years, however, it has become increasingly clear that steroids can relieve many types of headaches—not just those resulting from brain tumors. 2. What was the theoretical basis for the temporal pattern of classic brain tumor headache? It is still believed, to some degree, that the increased intracranial pressure that may occur with sleep and recumbency can increase pain caused by brain tumors. Mild CO2 retention during sleep leads to vasodilatation and increased pressure. Similarly, when the patient is recumbent, venous return from the brain decreases and intracranial pressure increases. As the patient awakens and ambulates, CO2 drops and venous return increases, thus lessening the headache pain as the day progresses. 3. How commonly do patients with brain tumors have the “classic history” of a brain tumor headache? The “classic” syndrome seems to occur in only about 17% of patients with brain tumors and headaches. Most commonly, headaches caused by brain tumor are diffuse, nondescript, and tensionlike. They are usually bilateral and commonly affect the vertex. 4. How often are brain tumor headaches unilateral? Pain is unilateral in less than 50% of brain tumor headaches. However, when it is unilateral, it is invariably felt on the side of the tumor. A migrainous presentation is highly unusual, occurring in only about 9% of patients with headaches caused by metastatic brain tumors. 5. If brain tumor headaches are most commonly tensionlike, how do you differentiate between a benign tension-type headache and a brain tumor headache? There are a number of factors that differentiate a tension-type headache from a brain tumor headache. The most important is probably the time course. A new-onset headache that progresses over days to weeks is much more suspect of representing a space-occupying lesion than is a chronic headache that has been stable over a long period. Furthermore, abnormalities on the neurologic exam are virtually unheard of in benign headache syndromes (with the exception of Horner’s sign in cluster headache) but occur in over 50% of patients with brain tumor headaches. Naturally, in a patient with a history of cancer and a new onset of headache, metastatic disease must be very high on the list. 6. Name and describe three circumstances under which extracerebral cancer can cause headache and/or facial pain Extracerebral cancer can cause headache and/or facial pain in the following circumstances: Obstruction of venous drainage of the brain produces increased intracranial pressure, with subsequent headache. Mediastinal tumors that compress the superior vena cava are a common example. Hypercoagulable states producing venous sinus thrombosis can produce severe headaches and depressed level of consciousness. 7. Is the pathology of the brain tumor important in determining the clinical presentation? No. Though the pathology of the brain tumor is not important in determining the clinical presentation, the location of the tumor may be. Tumors at the base of the skull are likely to produce cranial nerve signs; tumors in the hemispheres are associated with a hemiparesis or language dysfunction; and tumors that obstruct cerebrospinal fluid (CSF) flow produce little in the way of focal neurological dysfunction. 8. What is parinaud syndrome? Parinaud syndrome is characterized by difficulty with ocular convergence and upgaze. There is also light-near dissociation of pupillary reaction (pupils do not constrict well as a reaction to light, but constrict when the patient tries to look at something that is close to the nose). This constellation of signs is seen in tumors that compress the midbrain, such as pineal tumors. 9. What is a “ball-valve” headache? Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Neuroimaging in the Patient with Pain Cluster Headache Postoperative Pain Management Sympathetic Neural Blockade Cancer Pain Syndromes Temporary Neural Blockade Stay updated, free articles. Join our Telegram channel Join Tags: Pain Management Secrets Jun 14, 2016 | Posted by admin in PAIN MEDICINE | Comments Off on Brain Tumor Headaches Full access? Get Clinical Tree
CHAPTER 14 BRAIN TUMOR HEADACHES Ronald Kanner, MD FAAN FACP, Charles E. Argoff, MD 1. What is the classic description of brain tumor headache? Standard texts describe the classic brain tumor headache as a morning headache that may even wake the patient from sleep in the early hours. It improves as the day goes on and characteristically responds to aspirin and steroids. At one point, the “steroid test” was used as a diagnostic tool for brain tumor headaches. A dramatic response to steroid administration strengthened the diagnosis, on the theory that peritumor edema was resolving. Over the years, however, it has become increasingly clear that steroids can relieve many types of headaches—not just those resulting from brain tumors. 2. What was the theoretical basis for the temporal pattern of classic brain tumor headache? It is still believed, to some degree, that the increased intracranial pressure that may occur with sleep and recumbency can increase pain caused by brain tumors. Mild CO2 retention during sleep leads to vasodilatation and increased pressure. Similarly, when the patient is recumbent, venous return from the brain decreases and intracranial pressure increases. As the patient awakens and ambulates, CO2 drops and venous return increases, thus lessening the headache pain as the day progresses. 3. How commonly do patients with brain tumors have the “classic history” of a brain tumor headache? The “classic” syndrome seems to occur in only about 17% of patients with brain tumors and headaches. Most commonly, headaches caused by brain tumor are diffuse, nondescript, and tensionlike. They are usually bilateral and commonly affect the vertex. 4. How often are brain tumor headaches unilateral? Pain is unilateral in less than 50% of brain tumor headaches. However, when it is unilateral, it is invariably felt on the side of the tumor. A migrainous presentation is highly unusual, occurring in only about 9% of patients with headaches caused by metastatic brain tumors. 5. If brain tumor headaches are most commonly tensionlike, how do you differentiate between a benign tension-type headache and a brain tumor headache? There are a number of factors that differentiate a tension-type headache from a brain tumor headache. The most important is probably the time course. A new-onset headache that progresses over days to weeks is much more suspect of representing a space-occupying lesion than is a chronic headache that has been stable over a long period. Furthermore, abnormalities on the neurologic exam are virtually unheard of in benign headache syndromes (with the exception of Horner’s sign in cluster headache) but occur in over 50% of patients with brain tumor headaches. Naturally, in a patient with a history of cancer and a new onset of headache, metastatic disease must be very high on the list. 6. Name and describe three circumstances under which extracerebral cancer can cause headache and/or facial pain Extracerebral cancer can cause headache and/or facial pain in the following circumstances: Obstruction of venous drainage of the brain produces increased intracranial pressure, with subsequent headache. Mediastinal tumors that compress the superior vena cava are a common example. Hypercoagulable states producing venous sinus thrombosis can produce severe headaches and depressed level of consciousness. 7. Is the pathology of the brain tumor important in determining the clinical presentation? No. Though the pathology of the brain tumor is not important in determining the clinical presentation, the location of the tumor may be. Tumors at the base of the skull are likely to produce cranial nerve signs; tumors in the hemispheres are associated with a hemiparesis or language dysfunction; and tumors that obstruct cerebrospinal fluid (CSF) flow produce little in the way of focal neurological dysfunction. 8. What is parinaud syndrome? Parinaud syndrome is characterized by difficulty with ocular convergence and upgaze. There is also light-near dissociation of pupillary reaction (pupils do not constrict well as a reaction to light, but constrict when the patient tries to look at something that is close to the nose). This constellation of signs is seen in tumors that compress the midbrain, such as pineal tumors. 9. What is a “ball-valve” headache? Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Neuroimaging in the Patient with Pain Cluster Headache Postoperative Pain Management Sympathetic Neural Blockade Cancer Pain Syndromes Temporary Neural Blockade Stay updated, free articles. Join our Telegram channel Join Tags: Pain Management Secrets Jun 14, 2016 | Posted by admin in PAIN MEDICINE | Comments Off on Brain Tumor Headaches Full access? Get Clinical Tree
