It remains a popular notion that headache is a significant symptom in many patients with brain tumor, but it is actually infrequent, particularly as the heralding symptom of a tumor in an adult. While headache is sometimes stated to occur in one-third of brain tumor cases, this is certainly the result of the high frequency of cranial imaging in headache patients. Headache probably only arises if the tumor displaces major cerebral vessels or blocks the flow of CSF, but we have seen exceptions. The pain has no specific features; it tends to be deep seated, usually nonthrobbing (occasionally throbbing), and is described as aching or bursting. However, a major change in the pattern of an accustomed headache syndrome should raise suspicion of a structural lesion in the cranium. Physical activity and changes in position of the head may provoke pain, whereas rest sometimes diminishes it. Nocturnal awakening because of pain occurs in only a small proportion of brain tumor patients and is by no means diagnostic. Most headaches that awaken people at night are cluster-like headaches, hypnic headaches in the elderly, or those caused by caffeine withdrawal. Unexpected forceful (projectile) vomiting may punctuate brain tumor headache in its later stages, particularly in children, or as an early feature if the tumor is in the posterior fossa.
If unilateral, the headache is nearly always on the same side as the tumor. Pain from supratentorial tumors is felt anterior to the interauricular circumference of the skull; from posterior fossa tumors, it is felt behind this line. Bifrontal and bioccipital headaches from tumor coming on after unilateral headaches probably signify the development of increased intracranial pressure or hydrocephalus.
Having stated that headache is not to be equated with brain tumor, one cannot help but be impressed with its frequency in association with colloid cysts, and we have several times stumbled on the diagnosis when an odd, unexplained bilateral headache led to brain imaging. The mechanism of headache in cases of colloid cyst, if such a relationship is valid at all, is not simply one of blocking the flow of CSF at the foramina of Monro, as it is not predicated on the development of hydrocephalus. Restated, the presence of a colloid cyst does not assure that it is explanatory of a headache syndrome; furthermore, many cases of colloid cyst found on imaging or autopsy are not associated with headache. Additionally, Harris described exceptional headaches of paroxysmal type with intraand periventricular brain tumors, and others have commented on the same type of headache with parenchymal tumors. These are severe headaches that reach their peak intensity in a few seconds, last for several minutes or as long as an hour, and then subside quickly. When they are associated with vomiting, transient blindness, leg weakness causing “drop attacks,” and loss of consciousness, there is a possibility of brain tumor with greatly elevated intracranial pressure. With respect to its onset, this headache almost resembles that of subarachnoid hemorrhage, but the latter is far longer-lasting and even more abrupt in onset. In its entirety, this paroxysmal headache is most typical of the aforementioned colloid cyst of the third ventricle, but it can occur with other tumors as well, including craniopharyngiomas, pinealomas, and cerebellar masses.
Headaches of Temporal Arteritis (Giant Cell Arteritis) (See Also Chap. 33)