Treatment of Tumor Headaches
The recommended treatment for tumor headaches includes corticosteroids (dexamethasone 4-8 mg/day) as first-line therapy to reduce cerebral edema, with anticonvulsants only for patients with seizures, and appropriate analgesics based on pain severity. 1
Initial Management
Corticosteroid Therapy
- Dexamethasone is the primary treatment for tumor headaches, with recommended starting doses between 4-8 mg/day for most patients 1
- For patients with more severe symptoms or acute neurologic issues, higher doses up to 16 mg/day in divided doses or even approaching 100 mg/day may be considered 1
- Steroid dose should be tapered as quickly as clinically possible to minimize side effects including personality changes, suppressed immunity, metabolic derangements, insomnia, and impaired wound healing 1
- For incidentally discovered brain metastases without significant mass effect or edema, withholding steroids may be appropriate 1
Seizure Management
- Anticonvulsants should only be administered to patients who have experienced seizures or are undergoing surgery 1
- Prophylactic anticonvulsants are not recommended for patients with no history of seizures 1
- When needed, non-enzyme-inducing anticonvulsants (such as levetiracetam) are preferred to avoid interactions with chemotherapy and steroids 1
- Common first-line anticonvulsants include phenytoin, carbamazepine, levetiracetam, and valproic acid 1
- If anticonvulsants are started for surgery, consider discontinuation after the perioperative period 1
Pain Management
Analgesic Approach
- For mild to moderate pain, simple analgesics such as acetaminophen (650 mg every 4-6 hours, maximum 4g/day) can be used 1
- For moderate to severe pain, opioids are recommended as the mainstay of treatment 1
- Pain medication should be given on a regular schedule with supplemental doses for breakthrough pain when pain is continuous 1
Opioid Management
- Calculate dosage increases based on total opioid dose (scheduled and as-needed) taken in previous 24 hours 1
- For persistent pain, add extended-release or long-acting formulations to provide background analgesia 1
- Provide rescue doses of short-acting opioids for breakthrough pain 1
- Monitor for and manage common opioid side effects including constipation, nausea, pruritus, and sedation 1
Adjuvant Therapies
- For neuropathic pain components, consider antidepressants (e.g., nortriptyline 10-150 mg/day) or anticonvulsants (e.g., gabapentin 100-1200 mg three times daily) 1
- For pain associated with inflammation, consider NSAIDs or glucocorticoids 1
- Consider topical agents such as local anesthetics for localized neuropathic pain 1
Interventional Approaches
Indications for Interventional Consultation
- Pain likely to be relieved with nerve block 1
- Failure to achieve adequate analgesia without intolerable side effects 1
Interventional Options
- For head and neck pain: peripheral nerve blocks 1
- For unilateral pain syndromes: cordotomy may be considered 1
- Neurostimulation procedures for cancer-related symptoms 1
- Radiofrequency ablation for bone lesions 1
Important Considerations
Acetaminophen Use
- While acetaminophen is commonly used, recent evidence suggests it may not provide additional benefit in patients with cancer pain already on strong opioid regimens 2
- A randomized controlled trial showed no significant improvement in pain control or decrease in total opioid use when acetaminophen was added to strong opioids in cancer patients 2
- Use acetaminophen with caution or avoid it altogether when using combination opioid-acetaminophen products to prevent excess acetaminophen dosing and liver toxicity 1
Treatment of Underlying Cause
- Consider trial of radiation or chemotherapy for painful lesions likely to respond to antineoplastic therapies 1
- For rare patients with significant midline brain shift, compression of the ventricular system, hemorrhage, or massive brain edema, surgical decompression may be the first emergent priority 1