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Brain Tumor Headaches

Relation of Brain Tumors to Headaches – Headache in Subdural Hematoma and Brain Abscess

Relation of Brain Tumors to Headaches
Brain tumor is the most feared cause when it comes to headaches. Statistically, in 30% of headache cases brain tumor is a major concern. Yet, headache as a first symptom occurs only in 1% of brain tumors.

Some more statistics – in one study, only 5% of patients diagnosed with brain tumor or other mass in the brain had headaches as a presenting symptom and none had headache as a major concern!

Cause of Headache in Brain Tumors
Considering lack pain perception by the brain tissue, the above mentioned statistical observations are pretty logical. The following structures in the head are able to perceive pain: meninges (layers of connective tissue covering the brain on the outside), arteries, a periosteum (superficial layer of the skull bones), and the skin.

Brain mass lesions always produce symptoms of the brain damage first, or before the headache. Brain has a jelly-like consistency. Any locally generated pressure is immediately transferred to the surrounding brain tissue. As a result, any pain will appear only at the point when the meninges are stretched, which will occur only if the tumor is large enough.

As the tumor gets larger it destroys more and more brain tissue. Each particular brain area is responsible for some specific function. Once destroyed, a loss of this particular function becomes evident.

Typical First Symptoms of Brain Tumors
The very first symptoms of a brain tumor are usually subtle or insidious. Missing keys while typing, difficulty using mirrors while driving, tripping while walking on uneven surface or while running, brief involuntary movements in one of the limbs are some of the examples. These minor symptoms gradually progress and evolve into an obvious limb weakness, loss of a visual field, or lack of coordination with falls. A full-blown epileptic seizure without any warning is a very common presentation of a brain tumor.

Some brain tumors tend to bleed. In case of intracranial hemorrhage, the tumor reveals itself with an apparent set of symptoms and, yes, a headache may be one of them; but not the only one.

Basically, if someone has a headache without even subtle neurological symptoms and normal neurological examination, a brain tumor responsible for the headache is virtually impossible. Some silent, asymptomatic tumor can be ruled out only on the brain imaging, such as an MRI, but that tumor would not be responsible for the headache.

Tumors with a Headache as a First Symptom
As usual, there are some exceptions, which just confirm the rules.

Tumors outside the brain, like in the skull, cause headaches without any neurological symptoms and they are often very bad ones. They are usually metastases. This pain is constant, very disturbing, often worse at night, and might be either local or holocranial.

Another example is a small tumor in the wrong place. The brain inside the skull is suspended in the cerebrospinal fluid, which is constantly produced in one place and reabsorbed in the other. So, there is a constant flow. Sudden obstruction of this flow may cause a head position or strain related headache, sometimes with loss of consciousness, if the tumor is located next to the cerebrospinal fluid pathways. A colloid cyst of the third ventricle is an example.

Classically, brain tumor related headaches are described as a constant dull headache, which often gets worse at night. This description has a very poor diagnostic guidance. Chronic daily headaches are extremely common in sleep deprivation, sleep apnea, and depression. Nocturnal headaches are typical in cluster headaches, migraine and primary hypnic headaches.

Brain Tumor Diagnosis
The best diagnostic modality is a Brain MRI with a contrast. Bone metastases will be best seen on the CAT scan.

Who needs brain imaging and who doesn’t? It is mostly a judgement call. A general rule is that any headache with classical features of a specific primary headache syndrome does not need brain imaging. All others are better being imaged because it is too easy to get wrong.

Headache in Subdural Hematoma and Brain Abscess
There are multiple types of the brain mass lesions and they all share one of the characteristics – an expanding mass inside the skull. The most common is subdural hematoma.

Subdural Hematoma Headache

Headaches caused by subdural hematoma and a brain tumor are similar. Both are produced by expanding volume inside the head. Constant heaviness in the head often gets worse at night. Confusion and sometimes vomiting are common associates.
In subdural hematoma there is a blood accumulation in the subdural space, which is the gap between the dura (a thick and hard tissue film covering the skull inside) and the brain.

Causes and Symptoms of Subdural Hematoma

The most common reason for this type of hemorrhage is a rupture of the bridging veins.

Veins are low pressure vessels, so the blood leaks from them slowly. The most common cause of subdural hemorrhage is a head injury. In younger people symptoms of headache, vomiting, and confusion due to subdural hematoma develop relatively rapidly (within hours after the injury). So, it is hard to miss. In older people the story is different.

Spontaneous (lack of trauma history) subdural hematoma is not uncommon in older people and in the high risk patient groups. We are all gradually losing our nerve cells. Our brains are shrinking year after year.
The result is an increased subdural space (the gap between the skull and the brain). This change in anatomy produces two effects: bridging veins get stretched and the larger subdural space can accumulate more blood. As a result, stretched bridging veins are easier to damage and the larger subdural space allows more blood accumulation over a longer period of time, which obviously delays the symptoms.

Minor head injury in the elderly may be forgotten. Days or weeks later the first symptoms of headache and some confusion will appear. Blaming senior moments for these symptoms may lead to devastating consequences, permanent loss of some brain functions, or even death.

The other two common risk factors for subdural hematoma are hemodialysis and blood thinners, such as Coumadine.

Subdural Hematoma Treatment

Subdural hematoma treatment largely depends on the size of the blood clot and the symptoms. Asymptomatic SDH does not have to be treated. It is rather monitored by repeated neurological examinations and the brain imaging. Large, or rapidly expanding and symptomatic hematomas require surgical evacuation ASAP.

Brain Abscess

Brain abscess behaves similar to a rapidly growing tumor and, basically, causes the same symptoms as a brain tumor. Fever is not universally present (only 50%). In the past, brain abscess was a relatively common complication of a middle ear infection in children. Nowadays, the most common cause of the brain abscess is toxoplasmosis in AIDS patients.