The symptoms of a brain tumor are intermittent

02.09.2009 10:25

Headache with brain tumors: predisposition is essential - German headache day September 5th

Rita Wilp Press and public relations
German Migraine and Headache Society

A typical concern of headache patients is the uncertainty as to whether their pain is due to a cause other than the "normal migraine" or the "normal tension headache". Those affected often ask themselves the question: "Couldn't a brain tumor also cause my headache?" "In this case, it is particularly important to diagnose the causes of headaches in good time, before a brain tumor has increased the pressure in the brain due to its growth and this causes headaches," says Dr. Christoph Schankin, Neurological Clinic and Polyclinic, University of Munich Clinic. Information on headaches at

In the case of a headache, the question always arises as to whether it is a 'normal headache' (primary headache) or a headache caused by another disease (secondary headache). "In order to be able to assess this better, we have devoted ourselves in detail to the characterization of headache in brain tumors. In our study we found that risk factors for the occurrence of headaches in brain tumors are a pre-existing primary headache syndrome (migraine, tension headache) and a positive family history for Headaches, "said Dr. Pub. In contrast, the risk of headache is independent of tumor size, location and surrounding edema (swollen brain tissue around the tumor). Brain tumor headache can manifest itself as a primary headache. Magnetic resonance imaging of the brain should be performed in the event of headaches, if the headache syndrome is atypical or if the clinical examination reveals pathological findings (reflex differences, paralysis, visual or speech disorders). Such an examination is also important if headaches reappear in old age after years without symptoms.

In the current version of the International Headache Classification (IHCD-II) of the International Headache Society (IHS), a distinction is made between two types of headache in brain tumors, headache with increased intracranial pressure (indirect tumor effect, IHS 7.4.1.) And headache caused by direct tumor action (IHS 7.4.2). Both types begin in close temporal connection with the tumor diagnosis and improve quickly after therapy of the tumor. According to IHCD-II, they differ in headache characteristics: if the tumor has an indirect effect, signs of increased intracranial pressure are required (nausea, vomiting, worsening due to pressing, coughing, physical activity) and an attack-like appearance. In the case of direct tumor effects, it is required that the headache is localized and progressive overall with an increasingly severe course (progressive) and depends on the time of day (worse in the morning than in the evening) and worsened by coughing or bending over. The described symptoms of both sub-forms strongly overlap with the typical intracranial pressure symptoms (nausea, vomiting, increase in lying down, coughing, straining) that are known from cerebral haemorrhages, meningitis and traumatic brain injuries and are therefore certainly applicable to brain tumors that already have to lead to an increase in intracranial pressure. Against this background, the differences between IHS 7.4.1 and IHS 7.4.2 seem to be quantitative rather than qualitative, and the question arises as to how the headache manifests itself in brain tumors that have not yet led to an increase in intracranial pressure. This is particularly important against the background that a tumor should be recognized before it leads to an increase in intracranial pressure.

In a prospective study of 85 patients in a normal neurosurgical ward with brain tumors (22 meningiomas, 21 astrocytomas, 19 glioblastomas, 19 metastases), we examined the frequency, manifestation and clinical risk factors (1). The incidence of tumor-associated headache was 60 percent. The pain was mainly dull and pressing (59%), bilateral (49%) and could not be assigned to any particular region of the head. The median pain intensity was 6 out of 10 on the nominal pain scale (with 1 as minimal to 10 as maximal pain), the duration of pain in 49 percent of the cases between four hours and seven days. Nausea and vomiting were rare (18%), as was the worsening when coughing (2%), bending over (2%), in a horizontal position (6%) or during exercise (4%). Risk factors for the occurrence of headache in brain tumors were a pre-existing primary headache syndrome (migraine, tension headache) with an odds ratio (OR) of 9.3 and a positive family history for headache (OR 5.6). In contrast, the risk of headache is independent of tumor size, location and surrounding edema.

This study shows that the headache symptoms required in the headache classification with nausea, vomiting, increase when lying down, when coughing or straining are rare in brain tumor patients. Rather, the headache syndrome is similar to the primary tension headache. In addition, if there is a positive family history for headache or a previous headache history, there appears to be a genetic predisposition for headache in brain tumors, among other things. This suggests that the mechanism of brain tumor-associated headache is rather not dependent on the pressure of the brain, but rather overlaps with the mechanisms of primary headache. This example from everyday clinical practice is appropriate to this (2): A 57-year-old patient with a history of migraines had migraine attacks that are typical for her again after more than 20 years of freedom from headaches. The cause of this late recurrence of migraine attacks was an intracranial metastasis of a thyroid carcinoma.

[1] Schankin CJ, Ferrari U, Reinisch VM, Birnbaum T, Goldbrunner R, Straube A. Characteristics of brain tumor-associated headache. Cephalalgia. 2007; 27: 904-11.
[2] Schankin CJ, Wagner J, Elstner M, Reinisch VM, Straube A. [Migraine recurrence due to intracranial metastasis of a thyroid carcinoma]. Neurologist. 2008; 79: 465-9.

Contact Person:

Hospital of the University of Munich
Prof. Dr. Andreas Straube
Dr. Christoph Schankin
Neurological Clinic and Polyclinic
Marchioninistr. 15th
D-83177 Munich
[email protected]
[email protected]

Secretary General and Press Spokesman of the German Migraine and Headache Society
Prof. Dr. Dipl.-Psych. Peter Kropp
Institute for Medical Psychology in the Center for Neurology
at the Medical Faculty of the University of Rostock
Gehlsheimer Str. 20, D-18147 Rostock
Phone +49 381 4949530/31
Email [email protected]

Features of this press release:
Research results, scientific publications