Brain Tumour Headache: Red Flags and When to Scan

Most headaches are not caused by a brain tumour. A brain tumour headache has recognisable features: it is worse in the early morning, it gets worse with coughing, sneezing or exercise, it is relieved by vomiting, or it is a new type of headache for the patient. Recurrent headache with repeated vomiting, new seizures, or neurological changes such as weakness, vision loss or imbalance justify a CT scan or MRI.

That is the screening logic Dr. Sonal Gupta, Principal Director & HOD Neuro and Spine Surgery, Fortis Hospital, Shalimar Bagh, New Delhi, India, gives to referring doctors. Her point is practical: symptoms tell a doctor that a scan is needed, imaging tells the doctor whether a tumour is present and what it probably is, and only a biopsy, the examination of tumour tissue under the microscope, gives the final answer. This article covers each step, from the first symptom to a confirmed diagnosis. The classification of tumours that the diagnosis feeds into is explained in the complete guide to benign and malignant brain tumours.

Why brain tumour symptoms vary so much

The symptoms of a brain tumour depend on its size, its type and its location in the brain. The skull is a closed box, so a growing mass raises the pressure inside it, and a tumour also disturbs whatever the surrounding brain controls: movement, sensation, vision, hearing, balance, memory or behaviour. Two patients with tumours of the same size can therefore present in completely different ways.

One limit matters for every referring doctor. Dr. Gupta is clear that symptoms cannot differentiate a benign tumour from a malignant one. They indicate only that a brain tumour may be present. Nobody should be reassured, or alarmed, about the nature of a tumour on the strength of the symptoms alone.

Brain tumour headache: the red flags

Four headache characteristics should raise suspicion of a brain tumour. A recurrent headache is a common symptom of a brain tumour, and when it comes with repeated vomiting, Dr. Gupta advises that a brain tumour should be considered. Because headache is so common, she singles out these characteristics:

1. Early morning headache, present on waking.
2. Headache aggravated by coughing, sneezing or exercise.
3. Headache relieved by vomiting.
4. A new-onset headache of a kind the patient has never had in the past.

These features share a mechanism. Lying flat overnight and straining (coughing, sneezing, exertion) both raise the pressure inside the skull, so a headache driven by a mass tends to be worst on waking and to spike with straining. A headache that behaves this way is different in kind from the familiar, recurring tension headache or migraine a patient has lived with for years.

Other symptoms of a brain tumour

Beyond headache, Dr. Gupta lists the following symptoms as possible signs of a brain tumour:

• Seizures, also called fits, particularly when they recur.
• Problems with vision or hearing loss, with recurrent giddiness.
• Paralysis in any part of the body.
• Memory loss, or recent changes in behaviour.
• Numbness in the legs and arms.
• Changes in personality.
• Imbalance while walking.
• Intractable facial pain, meaning facial pain that does not respond to usual treatment.

Any of these, with or without headache, means the patient needs a CT scan or an MRI.

A referral question from the session

During the session, a referring doctor described a teenager whose headaches came on whenever he sat down to study for a while, together with an unpleasant noise in his head, to the point that he could not study. Dr. Gupta's answer was unequivocal: all such symptoms merit an MRI. She advised doing the MRI to establish whether a tumour is present and where it is, and offered to review the images or report and come back with an opinion. For a referring doctor, the lesson is that the threshold for imaging a young person with a new, persistent headache pattern should be low.

Seizures and brain tumours: why every seizure needs an MRI

A seizure can be the first sign of a brain tumour, but most seizures have other causes. Dr. Gupta holds two principles together.

First, every patient who has a seizure should have an MRI using the epilepsy protocol, with contrast added when a tumour or infection is suspected. An epilepsy protocol MRI uses dedicated high-resolution sequences aimed at the parts of the brain where seizures commonly start. A CT scan, she warns, can miss the small lesions that cause epilepsy, which is why she advises MRI so that nothing is missed. This applies to an adult with a first-ever seizure as much as to a patient with long-standing epilepsy.

Second, not every seizure disorder or epilepsy is caused by a brain tumour. A first seizure in an adult justifies looking for a tumour properly; it does not mean one is present.

Seizures and surgery: lesional and intractable epilepsy

Dr. Gupta's department performs epilepsy surgery, and her first clarification on the subject is that not every patient with epilepsy needs it. Epilepsy can occur with a lesion, a visible abnormality on the brain scan, or without one. Only two groups need surgery:

• Lesional epilepsy, where a structural lesion in the brain is causing the seizures.
• Intractable epilepsy, where seizures continue despite medication. Drug-resistant epilepsy is formally defined as failure of adequate trials of two tolerated, appropriately chosen and used anti-seizure medications.

For children, her answer on whether epilepsy surgery at an early age helps is yes: if a child is dependent on multiple anti-epileptic medications, an operation helps because it reduces the number of medicines needed, and with them their side effects.

The workup itself is specialised. When a referring doctor asked about a young man who had been on epilepsy medication and follow-up for 10 years, with a negative MRI but an EEG (a recording of the brain's electrical activity) showing slow waves, Dr. Gupta's advice was that the patient should come for a dedicated epilepsy workup.

Making epilepsy surgery accessible for patients abroad

For patients in Africa, Dr. Gupta proposes a staged route that avoids unnecessary travel. An online epilepsy clinic reviews which medicines the patient is taking and whether the epilepsy is genuinely intractable. Only if it is intractable is the patient brought to India for a full epilepsy surgery workup. In her view, this is the best way to make epilepsy surgery practical. For a detailed treatment of drug-resistant epilepsy and the operations available, see Dr. Dinesh Rattnani's guide to drug-resistant epilepsy workup and referral.

How a brain tumour is diagnosed

The common ways of diagnosing a brain tumour are CT scan, MRI and MR spectroscopy, with PET and SPECT scans in selected cases. Each answers a different question.

• CT scan (computed tomography) uses X-rays to produce cross-sectional images. It is fast and widely available, and it shows bleeding, calcification and large masses well.
• MRI (magnetic resonance imaging) uses a magnetic field rather than radiation and gives far more detailed images of brain tissue. It is the standard test for characterising a brain tumour and for planning surgery.
• MR spectroscopy is an MRI technique that measures the chemical make-up of a region of the brain, which helps distinguish tumour from other lesions and suggests how aggressive a tumour may be.
• PET and SPECT scans are nuclear medicine scans that show metabolic activity and blood flow. Dr. Gupta notes they may help to pick up widespread brain tumours and can assist diagnosis.
• Blood tests are usually not very helpful in diagnosing a brain tumour when done without the imaging above.

How accurate imaging is, and why biopsy is still needed

Taken together, CT, MRI and MR spectroscopy can tell whether a tumour is benign or malignant with an accuracy of about 90%, Dr. Gupta explains. The remaining uncertainty is why the diagnosis is completed by a biopsy. Only once tissue is sent for biopsy is it known whether the tumour is benign or malignant and what grade it is. For deep-seated tumours, the biopsy can be taken through a small hole in the skull using stereotactic biopsy, described in the article on brain tumour surgery and radiosurgery options.

For malignant tumours, the biopsy now feeds a further step. Dr. Gupta's team performs a genetic study on the tumour tissue. In her practice, whether chemotherapy or immunotherapy follows depends on the biopsy, and the outcome depends on both the biopsy report and the genetic study.

Diagnosing brain tumours in children and newborns

A brain tumour in a child is identified in the same way as in an adult: through the same symptoms and the same imaging.

A brain tumour can also be detected in a newborn. Dr. Gupta points out that, as a screening step, an ultrasound of the skull can show whether there is excess fluid in the brain or a tumour. In babies this works because the soft spot on the top of the head (the fontanelle) is still open and lets ultrasound through. Ultrasound is only a screening test, however. To be certain, even in a newborn, an MRI is required.

Brain tumour referral checklist for doctors

The diagnostic steps above translate into a short referral checklist:

• A patient with red-flag headache, seizures or new neurological symptoms needs an MRI.
• A seizure needs an MRI under the epilepsy protocol, with contrast when a tumour or infection is suspected.
• A newborn with a suspicious skull ultrasound needs an MRI.

With the MRI images or report in hand, a neurosurgeon can say whether there is a tumour, where it is and what it probably is, and plan biopsy and treatment from there. The specific cases and questions raised by referring doctors are collected in the Live Discussion with Dr. Sonal Gupta, and related conditions are gathered on the neuro and spine surgery hub.