What is the diagnosis and treatment for a 12-year-old female with headaches, diffuse abdominal pain, significant weight loss, and a tender lump on the forehead?

Urgent Neuroimaging Required for Suspected Intracranial Mass

This 12-year-old requires immediate MRI brain with and without contrast to evaluate for an intracranial mass lesion, most likely a brain tumor. The constellation of headaches worsening when lying down, interfering with sleep, significant weight loss, fatigue, diffuse abdominal pain, and a tender forehead lump represents multiple red flags that mandate urgent imaging and likely neurosurgical referral 1, 2, 3.

Critical Red Flags Present

This patient exhibits several concerning features that distinguish secondary from primary headache:

• Headaches worsening when lying down at night suggest increased intracranial pressure, as headaches aggravated by recumbent position indicate space-occupying lesions 1, 2, 3
• Awakening from sleep or interfering with sleep is a classic red flag for brain tumors and increased intracranial pressure 2, 3
• 10-pound weight loss in 3 weeks is a systemic symptom accompanying intracranial tumors in children 1
• Diffuse abdominal pain with headache may represent increased intracranial pressure or tumor-related symptoms, as 94% of children with brain tumors have accompanying symptoms beyond headache 1, 3
• Tender forehead lump could represent direct tumor extension, metastasis, or associated skull involvement 1
• 4-week duration with progressive pattern represents a rapidly changing headache pattern requiring immediate evaluation 2, 3

Immediate Diagnostic Approach

MRI brain with and without contrast is the mandatory first imaging study 1, 2, 3:

• MRI provides superior resolution without ionizing radiation and is the imaging modality of choice for suspected tumors 1
• Include sagittal T2-weighted sequences to evaluate the craniocervical junction 3
• Contrast enhancement is essential to characterize any mass lesions identified 1
• MRI is more sensitive than CT for detecting posterior fossa lesions and subtle mass lesions that commonly present with morning/nocturnal headaches 3

Physical examination must include 1, 3:

• Fundoscopic examination for papilledema (present in 60% of children with brain tumors at diagnosis) 1, 3
• Complete neurological examination including cranial nerves, gait assessment, cerebellar function, reflexes, and sensory testing 1, 4
• Measurement of head circumference if applicable 1

Why This Is Not Primary Headache

This presentation does not meet criteria for migraine or other primary headaches 2:

• Migraine headaches typically improve with lying down, not worsen 2
• The 4-week continuous pattern with nightly worsening does not fit episodic migraine (which requires 4-72 hour attacks) 2
• Significant weight loss and systemic symptoms are not features of primary headache 2
• The tender forehead mass is unexplained by primary headache disorders 1

While abdominal migraine exists in children and can present with abdominal pain and headache 5, 6, 7, it does not explain the forehead mass, weight loss, or headaches worsening with recumbency 5, 6.

Urgent Management Pathway

Immediate referral to emergency department or urgent neurology consultation (within 48 hours) 2, 4:

• Nearly all children with intracranial tumors have abnormal neurologic findings or accompanying symptoms at diagnosis 1, 3
• Any child with signs of increased intracranial pressure requires urgent imaging 1, 4, 3
• Emergency admission is indicated when red flags are present 2

Do not delay imaging for symptom trials 1, 2:

• Treatment with analgesics or migraine medications is inappropriate until secondary causes are excluded 2, 8
• The presence of multiple red flags makes primary headache diagnosis untenable 2, 8

Common Pitfalls to Avoid

• Do not attribute these symptoms to migraine based solely on age and headache presence—the red flags override any consideration of primary headache 1, 2, 3
• Do not obtain CT instead of MRI unless immediate availability is an issue, as CT is inferior for detecting many intracranial masses 1, 3
• Do not delay imaging to trial medications—the clinical presentation demands immediate structural evaluation 1, 2
• Do not dismiss the forehead lump as unrelated—it may represent direct tumor involvement or associated pathology 1