Brain tumor headaches: from bedside to bench

Chronic Neurological Complications of Brain Tumors and Brain Tumor Treatments

PURPOSE OF REVIEW

Chronic complications of brain tumors and brain tumor treatments can lead to impairment of health-related quality of life and decreased functionality. These largely include cognitive decline, fatigue, headache, seizures, and secondary malignancies. Outpatient neurologists are an integral part of the multidisciplinary neuro-oncology team who help diagnose and manage chronic complications in this complex patient population. Timely diagnosis and treatment of these complications in outpatient neurology and neuro-oncology clinics helps improve quality of life and survival of brain tumor patients.

RECENT FINDINGS

We discuss updated information and management regarding various chronic neurologic complications among neuro-oncology patients. Understanding of chronic neurologic complications associated with central nervous system tumors and with common contemporary cancer treatments will facilitate neurologists management of these patient populations. While there are aspects analogous to the diagnosis and management in the non-oncologic population, a number of unique features discussed in this review should be considered.

MicroRNA-146 family: Molecular insights into their role in regulation of signaling pathways in glioma progression

Glioma is a highly lethal brain cancer in humans. Despite advancements in treatment, the prognosis for patients remains unfavorable. Epigenetic factors, along with their interactions and non-coding RNAs (ncRNAs), are crucial in glioma cells' development and aggressive characteristics. MicroRNAs (miRNAs) are a class of small non-coding RNAs (ncRNAs) that modulate the expression of various genes by binding to target mRNA molecules. They play a critical role in regulating essential biological mechanisms such as cell proliferation and differentiation, cell cycle, and apoptosis. MiR-146a/miR-146b is a significant and prevalent miRNA whose expression alterations are linked to various pathological changes in cancer cells, as well as the modulation of several cellular signaling pathways, including NF-κB, TGF-β, PI3K/Akt, and Notch-1. Scientists may identify novel targets in clinical settings by studying the complicated link between Mir-146a/mir-146b, drug resistance, molecular pathways, and pharmacological intervention in gliomas. Additionally, its interactions with other ncRNAs, such as circular RNA and long non-coding RNA, contribute to the pathogenesis of glioma. As well as miR-146 holds potential as both a diagnostic and therapeutic biomarker for patients with this condition. In the current review, we investigate the significance of miRNAs in the context of glioma, with a particular focus on the critical role of Mir-146a/mir-146b in glioma tumors. Additionally, we examined the clinical relevance of this miRNA, highlighting its potential implications for diagnosis and treatment.

Headache Management in Individuals with Brain Tumor

Headache occurs commonly in individuals diagnosed with cerebral neoplasm. Though the features of a brain tumor-associated headache may vary, a progressive nature of headache and a change in headache phenotype from a prior primary headache disorder often are identified. Pathophysiologic mechanisms proposed for headache associated with brain tumor include headache related to traction on pain-sensitive structures, activation of central and peripheral pain processes, and complications from surgical, chemotherapeutic and/or radiotherapy treatment(s). Optimization of headache management is important for an individual's quality of life. Treatments are based upon patient-specific goals of care and may include tumor-targeted medical and surgical interventions, as well as a multimodal headache treatment approach incorporating acute and preventive medications, nutraceuticals, neuromodulation devices, behavioral interventions, anesthetic nerve blocks, and lifestyles changes.

The Natural History and Treatment of Meningiomas: An Update

Meningiomas are the most frequent nonmalignant tumors of the central nervous system (CNS). Despite their benign nature and slow-growing pattern, if not diagnosed early, these tumors may reach relatively large sizes causing significant morbidity and mortality. Some variants are located in hard-to-access locations, compressing critical neurovascular structures, and making the surgical management even more challenging. Although most meningiomas have a good long-term prognosis after treatment, there are still controversies over their management in a subset of cases. While surgery is the first-line treatment, the use of fractionated radiotherapy or stereotactic radiosurgery is indicated for residual or recurrent tumors, small lesions, and tumors in challenging locations. Advances in molecular genetics and ongoing clinical trial results have recently helped both to refine the diagnosis and provide hope for effective biomolecular target-based medications for treatment. This article reviews the natural history and current therapeutic options for CNS meningiomas.

Overview on Common Genes Involved in the Onset of Glioma and on the Role of Migraine as Risk Factor: Predictive Biomarkers or Therapeutic Targets?

Gliomas are relatively rare but fatal cancers, and there has been insufficient research to specifically evaluate the role of headache as a risk factor. Nowadays, gliomas are difficult to cure due to the infiltrative nature and the absence of specific adjuvant therapies. Until now, mutations in hundreds of genes have been identified in gliomas and most relevant discoveries showed specific genes alterations related to migraine as potential risk factors for brain tumor onset. Prognostic biomarkers are required at the time of diagnosis to better adapt therapies for cancer patients. In this review, we aimed to highlight the significant modulation of CLOCK, BMLA1 and NOTCH genes in glioma onset and development, praising these genes to be good as potentially attractive therapeutic markers for brain tumors. A improved knowledge regarding the role of these genes in triggering or modulating glioma maybe the key to early diagnosing brain tumor onset in patients affected by a simple headache. In addition, investigating on these genes we can suggest potential therapeutic targets for treating brain tumors. These considerations open up the possibility of personalized treatments that can target each brain tumor's specific genetic abnormality.

Headache Attributed to Non-vascular Intracranial Disorder: Neoplasms, Infections, and Substance Abuse

Evaluation of headaches warrants a careful history and neurologic assessment to determine the need for further workup and imaging. Identifying patients who are at risk for underlying pathology is important and this includes individuals with known or suspected malignancy and those who are immunocompromised and at increased risk for intracranial infection. While CT is helpful in the acute setting and to screen for intracranial hypertension, MRI is the modality of choice for the evaluation of underlying pathologies. Imaging in substance abuse may show injury related to direct toxicity or secondary to vascular complications.

Visual Aura Secondary to Supratentorial Lipomatous Meningioma: A Rare Case Report

Background/Aim: Lipomatous meningioma is a rare type of meningioma that is formed as the result of an accumulation of lipids inside the cell due to metabolic activity dysregulation. It differs from other types of meningiomas in its radiological and immunohistochemical characteristics. We report a rare case of a patient treated in our department for this particular type of meningioma who developed a type of migraine with the aura component as the first clinical symptom. Case Report: A 55-year-old woman presented with a migraine and reported having phosphenes in recent years. Head Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) scans were performed; these showed an extensive hypodense and hypointense formation located in the left parieto-occipital region. This formation was implanted in the tentorium region, with a prevailingly adipose-type signal intensity. The patient underwent an occipital craniotomy with the total removal of the lesion. The histological examination indicated a lipomatous metaplastic meningioma. Conclusion: We reported the first case of a lipomatous meningioma presenting with a migraine with a visual aura. Seizures and headaches can be included as possible symptoms. According to the current literature, lipomatous meningiomas affect women more commonly than men. The patient of our reported case presented visual disturbances in the form of a visual aura, which occurred 10 years before finding the meningioma, and surgery dramatically improved the symptoms and quality of life.

Hemorrhagic Pseudocyst: A Rare Cerebral Mass Lesion Causing Death. A Case Report and Brief Review of Literature

ABSTRACT

Mass lesions in the brain encompass a wide range neoplastic and nonneoplastic entities. These can present as a diagnostic pitfall, with nonspecific, overlapping symptoms and similar appearances on radiology. They may cause death through varied mechanisms, either specific to the underlying pathophysiology or due to the space-occupying effect of the lesion. We report a case of fatal hemorrhagic cerebral pseudocyst, a rare mass lesion, associated with a cerebral varix, causing death in a morbidly obese individual. To the best of our knowledge, there is no previous documentation in the postmortem literature of this entity as a cause of death. This case aims to document this rare entity in the differential diagnosis of a tumor-like lesion in the brain, highlight the clinical difficulty in its assessment, and demonstrate an uncommon mechanism of death, of a mass lesion acting as a focus causing seizures, with resulting hypoxia due to effects of morbid obesity and heart failure.

Update on headache and brain tumors

Headache is one of the leading symptoms often associated with brain tumours. Secondary headaches attributed to intracranial neoplasias have been included in subchapter 7.4 of the third edition of the International Classification of Headache Disorders (ICHD-3). According to ICHD-3, the headache may be attributed to a brain tumour if it has developed in close temporal relation with the development of the neoplasia, has significantly worsened in parallel with the worsening of the tumour, and/or has significantly improved following the successful treatment of the neoplasia. Brain tumour headache was traditionally thought to display some specific clinical characteristics, including worsening in the morning and/or when lying down, being aggravated by Valsalva-like manoeuvres and accompanied by nausea and/or vomiting; however, the studies performed after the advent of modern neurodiagnostic techniques have pointed out that the "classic" brain tumour headache is uncommon, particularly at the time of clinical presentation. Therefore, it becomes critical to seek some specific factors associated with the presence of an intracranial mass (the so-called "red flags") that can guide the physician to establish an accurate diagnosis.

The Most Common Causes of Eye Pain at 2 Tertiary Ophthalmology and Neurology Clinics

BACKGROUND

Eye pain is a common complaint, but no previous studies have determined the most common causes of this presenting symptom. Our objective was to determine the most common causes of eye pain in 2 ophthalmology and neurology departments at academic medical centers.

METHODS

This was a retrospective cross-sectional analysis and chart review at the departments of ophthalmology and neurology at the University Hospital Zurich (USZ), University of Zürich, Switzerland, and the University of Utah (UU), USA. Data were analyzed from January 2012 to December 2013. We included patients aged 18 years or older presenting with eye pain as a major complaint.

RESULTS

Two thousand six hundred three patient charts met inclusion criteria; 742 were included from USZ and 1,861 were included from UU. Of these, 2,407 had been seen in an ophthalmology clinic and 196 had been seen in a neurology clinic. Inflammatory eye disease (conjunctivitis, blepharitis, keratitis, uveitis, dry eye, chalazion, and scleritis) was the underlying cause of eye pain in 1,801 (69.1%) of all patients analyzed. Although only 71 (3%) of 2,407 patients had migraine diagnosed in an ophthalmology clinic as the cause of eye pain, migraine was the predominant cause of eye pain in the neurology clinics (100/196; 51%). Other causes of eye pain in the neurology clinics included optic neuritis (44 patients), trigeminal neuralgia, and other cranial nerve disorders (8 patients).

CONCLUSIONS

Eye pain may be associated with a number of different causes, some benign and others sight- or life-threatening. Because patients with eye pain may present to either a neurology or an ophthalmology clinic and because the causes of eye pain may be primarily ophthalmic or neurologic, the diagnosis and management of these patients often requires collaboration and consultation between the 2 specialties.

Top Ten Tips Palliative Care Clinicians Should Know When Caring for Patients with Brain Cancer

The diagnosis of an aggressive, primary brain tumor is life altering for those affected and too often portends a poor prognosis. Despite decades of research, neither a cure nor even a therapy that reliably and dramatically prolongs survival has been found. Fortunately, there are a number of treatments that may prolong the life of select brain tumor patients although the symptom burden can sometimes be high. This article brings together neuro-oncologists, neurologists, and palliative care (PC) physicians to help shine a light on these diseases, their genetics, treatment options, and the symptoms likely to be encountered both from the underlying illness and its treatment. We hope to increase the understanding that PC teams have around these illnesses to improve care for patients and families.

Secondary Headache Syndromes

PURPOSE OF REVIEW

This article is intended to assist clinicians in distinguishing benign primary headache syndromes from serious headache presentations that arise from exogenous causes.

RECENT FINDINGS

Although most cases of severe headache are benign, it is essential to recognize the signs and symptoms of potentially life-threatening conditions. Patients with primary headache disorders can also acquire secondary conditions that may present as a change in their baseline headache patterns and characteristics. Clinical clues in the history and examination can help guide the diagnosis and management of secondary headache disorders. Furthermore, advances in the understanding of basic mechanisms of headache may offer insight into the proposed pathophysiology of secondary headaches.

SUMMARY

Several structural, vascular, infectious, inflammatory, and traumatic causes of headache are highlighted. Careful history taking and examination can enable prompt identification and treatment of underlying serious medical disorders causing secondary headache syndromes.

Craniopharyngioma in a young woman with symptoms presenting as mechanical neck pain associated with cervicogenic headache: a case report

Background: Craniopharyngioma is benign neoplasm thought to be caused by mal-development, which occurs in both children and adults in the sellar and suprasellar regions of the brain. Typical manifestations in adults are visual and endocrine system symptoms followed by signs and symptoms of increased intracranial pressure (i.e., headache). The management of this rare condition is complex and requires life-long surveillance by a multidisciplinary team of health-care professionals.Objective: To present a rare clinical presentation of craniopharyngioma mimicking nonspecific neck pain usually associated with cervicogenic headache recognized by a physiotherapist in a direct access setting as a condition requiring medical referral.Case Presentation: This case report describes the history, examination findings, and clinical reasoning used in the initial examination of a 33-year-old female with neck pain and cervicogenic headache as chief complaints. Several key indicators in the patient presentation warranted further and urgent investigation: 1) the recent onset of a "new-type" headache; 2) the phenotype headaches change; 3) the rapid progression of the symptoms; 4) the presence of associated neurological signs and symptoms; and 5) the worsening of the symptoms during Valsalva-like activities. The decision was made to refer the patient for further evaluation. An MRI revealed a craniopharyngioma. After a surgical removal of the tumor mass, the patient participated in a rehabilitation program and reached a full recovery after 6 months.Conclusion: This case report highlights the need of more research regarding red flags and warning signs during examination of in the head-neck region, and the central role of primary care clinicians such as physiotherapists in differential diagnosis of life-threatening conditions.

Association of migraines with brain tumors: a nationwide population-based study

BACKGROUND

Several studies examined headaches as a symptom of brain neoplasms. Nevertheless, very few studies attempted to specifically evaluate the role of headaches as a risk factor. This study aimed to investigate the risk of migraine occurrence in the preceding years among patients diagnosed with brain tumors and unaffected controls.

METHODS

Data were obtained from the Taiwan National Health Insurance Research Database. In total, 11,325 adults with a first-time brain tumor diagnosis were included as cases, together with 11,325 unaffected matched controls. Each individual was traced in the healthcare claims dataset for a prior diagnosis of migraines. Conditional logistic regressions were performed to calculate the odds ratio (OR) and the corresponding 95% confidence interval (CI) to present the association between brain tumors and having previously been diagnosed with migraines.

RESULTS

We found that among patients with and those without brain tumors, 554 (4.89%) and 235 (2.08%) individuals, respectively, were identified as having a prior migraine diagnosis. Compared to unaffected controls, patients with brain tumors experienced an independent 2.45-fold increased risk of having a prior migraine diagnosis. The risks were even higher among men (odds ratio (OR) = 3.04, 95% confidence interval (CI) = 2.29~ 4.04) and after patients who had received a prior migraine diagnosis within 3 years were excluded (OR = 1.91, 95% CI = 1.59~ 2.29).

CONCLUSIONS

This is the first report demonstrating the occurrence of brain tumors to be associated with a prior migraine history, for both men and women, in a population-based study.

PPIENSENLo: A Novel Mnemonics in Spanish for Alarm Criteria in Secondary Headaches in Children

We present the first mnemonic in Spanish, "PPIENSENLo," for alarm criteria in secondary headaches in children in order to facilitate their identification, diagnosis, and treatment. A search was performed across different electronic databases for a mnemonics that applied to clinical alarm criteria in secondary headaches in children. None were found in English or Spanish. This tool is perhaps useful both for clinical and teaching purposes.

Brain metastasis: clinical manifestations, symptom management, and palliative care

Patients who have brain metastases can suffer from a medley of symptoms, including headaches, seizures, cognitive impairment, fatigue, and focal deficits. As therapies have evolved, so has the management of these symptoms as patients survive longer. This chapter focuses on the clinical presentation of brain metastases, the treatment of those symptoms, and palliation in end-of-life management. Brain metastases are the most common cerebral malignancy. They can present with various symptoms, which can have significant impact on patients' quality of life throughout the course of their disease. Most of these symptoms are related to direct brain compression from the tumor or from edema. The location of the metastases will determine the focal deficits incurred and most patients will be on a course of steroids tapered according to their clinical status. The chapter includes a list of potential side-effects and considerations for management. Palliative care is an essential and important part of approaching patients with metastases. Early and clear communication about end-of-life decision making is encouraged with multiple easily accessible tools. For patients near the end of life, comfort is the ultimate goal in providing a good quality of life.

Epidemiology of glioma: clinical characteristics, symptoms, and predictors of glioma patients grade I-IV in the the Danish Neuro-Oncology Registry

In this national population-based study of glioma, we present epidemiologic data on incidence, demographics, survival, clinical characteristics and symptoms, and evaluate the association of specific indicators with the grade of glioma. We included 1930 patients registered in the Danish Neuro-Oncology Registry (DNOR) from 2009 to 2014. DNOR is a large-scale national population-based database including all adult glioma patients in Denmark. The age-adjusted annual incidence of histologic verified glioma was 7.3 cases pr. 100,000 person-years. High-grade gliomas were present in 85% and low-grade glioma in 15%. The overall male:female ratio was 3:2 and the mean age at onset was 60 years. Data for WHO grade I, II, III and IV glioma showed several important differences regarding age and sex distribution and symptomatology at presentation. The mean age increased with the grade of glioma and males predominated in all grades. Focal deficits were the most frequent presenting symptom, but among patients with glioma, grade II epileptic seizures were the most frequent symptom. Headache was a rare mono-symptomatic onset symptom. At presentation, higher age, focal deficits and cognitive change for <3 months duration, and headache <1 month were significant independent indicators of high-grade gliomas. Younger age and epileptic seizures for more than 3 months were indicative for low-grade gliomas. Survival rates for glioma grade I-IV showed decreasing survival with increasing grade. Glioma grade I-IV showed high diversity regarding several demographic and clinical characteristics emphasizing the importance of individually tailored disease treatments and support.

Headache as a presenting symptom of glioma: A cross-sectional study

Objective

The objective of this study was to analyse the prevalence and the clinical features of headache as a presenting symptom of glioma.

Methods

We interviewed 527 consecutive adult patients with histologically confirmed glioma, admitted to the Regina Elena National Cancer Institute between 2010 and 2015. We defined four headache phenotypes: Tension-type-like headache (TTH), migraine-like headache, worsening of a pre-existing headache (WPH) and classic brain tumour headache (BTH). Logistic regression analysis was carried out to investigate potential risk factors for headache at presentation of glioma.

Results

12.5% (n = 66) of patients with glioma indicated headache as a presenting symptom of their disease. Of these, 31 patients (47%) had TTH, while BTH and WPH were reported by 28 (42%) and seven (11%) patients, respectively. We did not find any case of migraine-like headache. Infratentorial ( p = 0.038) and right-sided tumours ( p = 0.013) were more frequently associated with the presence of headache at onset. Patients with TTH were older than patients with BTH and WPH ( p = 0.035). BTH was less frequently associated with other neurological signs ( p < 0.0001). The multivariate logistic regression analysis showed the localization of the brain tumour in the left hemisphere to be a protective factor for the development of headache.

Conclusions

Our study includes a very large series of patients with glioma, providing a description of headache phenotype at first presentation of disease and investigating possible factors that may influence the clinical features of headache.

Headache in Patients With Pituitary Lesions: A Longitudinal Cohort Study

BACKGROUND

Headache is a presenting feature in 37% to 70% of patients with pituitary tumor. Other pituitary lesions may also present with headache, and together these lesions account for about 20% of all primary brain lesions. Although pituitary lesions have been associated with headache, the exact nature of the relationship remains undefined. It is not always clear whether the presenting headache is an unrelated primary headache, a lesion-induced aggravation of a preexisting primary headache, or a separate secondary headache related to the lesion.

OBJECTIVE

To characterize headache in patients referred to a multidisciplinary neuroendocrine clinic with suspected pituitary lesions and to assess changes in headache in those who underwent surgery.

METHODS

We used a self-administered survey of headache characteristics completed by patients upon presentation and after any pituitary surgical procedure.

RESULTS

One hundred thirty-three participants completed the preoperative questionnaire (response rate of 99%). The overall prevalence of headache was 63%. Compared to patients without headache, the group with headache was more likely to be female (P = .001), younger (P = .001), and to have had a prior headache diagnosis (P < .001). Seventy-two percent of patients reported headache localized to the anterior region of the head. Fifty-one patients with headache underwent transsphenoidal pituitary surgery. Headache was not associated with increased odds of having surgery (odds ratio, 0.90). At 3 months, 81% of surgically treated patients with headache who completed the postoperative questionnaire (21/26) reported improvement or resolution of headaches. No patient who completed the postoperative questionnaire (44/84) reported new or worsened headache.

CONCLUSION

Frequent, disabling headaches are common in patients with pituitary lesions referred for neuroendocrine consultation, especially in younger females with a preexisting headache disorder. Surgery in this group was associated with headache improvement or resolution in the majority and was not found to cause or worsen headaches. Suggestions for revision of the International Classification of Headache Disorders diagnostic criteria pertaining to pituitary disorders are supported by these findings.

Headaches in brain tumor patients: primary or secondary?

BACKGROUND

Headaches occur commonly in all patients, including those who have brain tumors. It has been argued that there is a classic "brain tumor headache type" - defined by the International Headache Society as one that is localized, progressive, worse in the morning, aggravated by coughing or bending forward, develops in temporal and often spatial relation to the neoplasm, and resolves within 7 days of surgical removal or treatment with corticosteroids.

METHODS

Using the search terms "headache and brain tumors," "intracranial neoplasms and headache," and "facial pain and brain tumors," we reviewed the literature from the past 20 years on brain tumor-associated headache and reflected upon the International Classification of Headache Disorders-3 (ICHD-3). In a separate, complementary paper, the proposed mechanisms of brain tumor headache are reviewed.

RESULTS

We discuss multiple clinical presentations of brain tumor headaches, present the ICHD-3 diagnostic criteria for each type of headache, and then apply our findings to the ICHD-3. Our primary and major finding was that brain tumor headaches can present similarly to primary headaches in those with a predisposition to headaches, suggesting that following ICHD-3 criteria could cause a clinician to overlook a headache caused by a brain tumor. We further find that some types of headaches are not explicitly discussed in the ICHD-3 and also propose that the International Headache Society formally define SMART (Stroke-like Migraine Attacks after Radiation Therapy) syndrome given the increasing amount of literature on this disorder.

CONCLUSION

Our literature review revealed that brain tumor headache uncommonly presents with classic brain tumor headache characteristics and often satisfies criteria for a primary headache category such as migraine or tension-type. Thus, clinicians may miss headaches due to brain tumors in following ICHD-3 criteria, and the distinction between primary and secondary headache disorders may not be so clear-cut.

Essential competencies in palliative medicine for neuro-oncologists

Palliative care is an approach to practicing medicine that addresses symptom management, alleviation of pain, assessment of psychosocial and spiritual distress or suffering, and practical support for patients and their caregivers with a goal of improving quality of life for patients with serious and life-threatening illnesses. Although palliative care has gained acceptance as an important part of comprehensive cancer care at the end of life, early integration of palliative care is less common. Patients with high-grade malignant gliomas have an invariably poor prognosis and high morbidity. With short survival times and complex neurological and systemic symptoms, these patients require palliative care from the time of diagnosis. In this review, we highlight the palliative care needs of neuro-oncology patients at diagnosis, during treatment, and at the end of life. We identify some of the barriers to incorporation of palliative care in standard neuro-oncology practice and equate competency in neuro-oncology with competency in the basic tenets of palliative medicine.

Presenting symptoms of glioma in adults

OBJECTIVE

Studies on the presenting symptoms of glioma in adults in the age of readily available MRI imaging are scarce. This study investigates presenting symptoms of glioma and assesses the correlations of the presenting symptoms with patient age and histopathological class of the tumor.

MATERIALS AND METHODS

A retrospective review of the medical records of histologically verified glioma patients treated in Turku University Hospital, during 2006-2010, was conducted. The associations between the presenting symptoms and other covariates were assessed individually.

RESULTS

One hundred and fifty patients were ascertained. The most common presenting symptoms of glioma were seizure and cognitive disorder. Patients presenting with seizures were younger than patients with cognitive disorders, and the grade of the tumor was also found to significantly correlate with the most common presenting symptoms. Age group and tumor grade were statistically significant factors of cognitive disorder (P = 0.0037 and P = 0.0069) and age group of seizure (P = 0.0065). The associations between the presenting symptoms and the anatomical location, spread into adjacent brain areas, or laterality of the tumor or site of diagnosis were found to be statistically insignificant. Headache was not a common presenting symptom in glioma patients.

CONCLUSIONS

The main presenting symptoms of glioma in adults in the MRI age still are seizures and cognitive disorder. Patient age and tumor grade correlate positively with the incidence of cognitive disorder and patient age negatively with incidence of seizure as a presenting symptom. Headache is an uncommon manifestation and does not appear as a sole symptom.

Headaches in children with craniopharyngioma

Craniopharyngioma frequently involves intracranial pain-sensitive structures. We retrospectively studied prevalence, associated risk factors, and outcome of headaches in children with craniopharyngioma. Fisher exact test and multivariate analysis were used to study association of study variables. Of the 51 craniopharyngioma patients treated at our institution from January 1994 to December 2005, 40 (78%) reported headaches (35 [68%] before tumor diagnosis). Migraine headaches were diagnosed in 32 (63%) and tension-type headaches in 11 patients (22%). The median follow-up period was 2.7 years. At the last follow-up, 38 (75%) were headache free. Presence of hydrocephalus, distortion of circle of Willis, and large tumor volume were associated with headache, and the last 2 variables were also associated with more severe and frequent headaches. Radiation treatment and insertion of Ommaya reservoir were associated with reduced headache frequency. In conclusion, headaches are common in patients with craniopharyngioma and are likely related to tumor size and volume. In most patients, headaches improve with successful tumor treatment.

Factors that cause concern

Headaches can be benign or life threatening but, with careful attention to the details described in this article, the correct diagnosis and treatment can be arrived at in many cases. Modern imaging techniques have taken the guesswork out of many conditions but a high index of suspicion and attention to red flags helps avoid potential adverse outcomes in headache encounters in a high proportion of cases.