From the Guidelines
The initial workup for a patient with breast cancer history presenting with headache and tinnitus should include urgent neuroimaging with contrast-enhanced MRI of the brain or CT with contrast if MRI is unavailable, as well as a comprehensive audiological evaluation to assess the tinnitus, as recommended by the most recent guidelines 1. The workup should also include a complete neurological examination, vital signs with particular attention to blood pressure (to rule out hypertensive causes), and basic laboratory tests including complete blood count, comprehensive metabolic panel, and inflammatory markers.
- Key considerations in the workup include:
- Evaluating for brain metastases, which occur in a significant proportion of breast cancer patients
- Assessing for symptoms of depression and anxiety, which are common in breast cancer survivors, using tools such as the distress thermometer, Patient Health Questionnaire-9, and Generalized Anxiety Disorder 7-item scale 1
- Considering further staging with CT chest/abdomen/pelvis and possibly a bone scan if neuroimaging reveals metastatic disease
- Evaluating the need for lumbar puncture with CSF analysis if leptomeningeal disease is suspected, particularly with multifocal neurologic symptoms or if imaging is inconclusive This comprehensive approach is necessary because neurologic symptoms in breast cancer survivors warrant prompt evaluation to distinguish between benign causes and potentially life-threatening cancer recurrence, as early detection of brain metastases significantly impacts treatment options and prognosis.
- The American Academy of Otolaryngology and Head and Neck Surgery Foundation (AAO-HNS) guidelines recommend targeted history and clinical examination as the initial evaluation and determination as to whether the tinnitus is bothersome or not, before any imaging 1. The most recent and highest quality study 1 prioritizes a comprehensive audiological evaluation and targeted history and clinical examination in the initial workup for tinnitus, which is essential in guiding the choice of imaging studies and their appropriateness.
From the Research
Initial Workup for Breast Cancer Patients with Headache and Tinnitus
The initial workup for a patient with a history of breast cancer presenting with headache and tinnitus should focus on ruling out metastatic disease and other potential causes of these symptoms.
- Imaging Studies:
- Breast MRI is a sensitive tool for detecting breast cancer and may be useful in evaluating the extent of disease and detecting additional tumor foci 2.
- Contrast-enhanced imaging modalities such as dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), contrast-enhanced mammography (CEM), and dedicated breast computed tomography (dCEBCT) can provide comprehensive insights into disease extent and characterization of lesions 3.
- Clinical Evaluation:
- A thorough clinical evaluation, including a physical examination and medical history, is essential to identify potential causes of headache and tinnitus.
- The evaluation should also consider the patient's history of breast cancer and any previous treatments.
- Diagnostic Tools:
- Mammography and ultrasound may be used as initial diagnostic tools, but their limitations, such as high false-positive and false-negative rates in women with dense breasts, should be considered 4, 5.
- Breast MRI and other contrast-enhanced imaging modalities may be used to improve lesion characterization and detection of breast cancer 2, 3.