Do brain mass lesions always cause constant headaches in patients with a history of worsening headaches when laying down or bending over, previously treated with metoclopramide (Reglan) and ketorolac (Toradol)?

Brain Mass Lesions and Headache Patterns

Brain mass lesions do not always cause constant headaches—in fact, headaches are present in only approximately 48-60% of patients with brain tumors, and when present, they are typically intermittent rather than constant. 1, 2, 3

Headache Frequency in Brain Tumors

• Headaches occur in approximately 48-60% of patients with brain tumors, meaning that 40-52% of patients with brain masses have no headache at all 2, 3
• The presence or absence of headache is not universal, with anecdotal reports of patients having large tumors with increased intracranial pressure but complete absence of headache pain 2
• Both primary and metastatic brain tumors show similar rates of headache presentation 3

Typical Headache Characteristics When Present

The "classic" brain tumor headache described in older literature is actually uncommon, particularly at the time of clinical presentation. 4, 3

When headaches do occur with brain masses, they typically present as:

• Tension-type pattern in 77% of cases—bifrontal but worse ipsilaterally, rather than the stereotypical severe morning headache 3
• Migraine-type pattern in only 9% of cases 3
• Headaches that worsen with bending over or lying down in 32% of patients 3
• Associated nausea or vomiting in 40% of patients 3

The traditional "classic" brain tumor headache (worse in morning, aggravated by Valsalva maneuvers, accompanied by nausea/vomiting) is uncommon and should not be relied upon for diagnosis. 4, 3

Factors Influencing Headache Presence

Several factors determine whether a brain mass will cause headache:

• Tumor location: Posterior fossa tumors cause headache more frequently than supratentorial tumors 5
• Growth rate: Rapidly growing tumors are more likely to be associated with headache 5
• Tumor size: Surprisingly, size does not reliably predict headache presence 2
• Pre-existing headache disorders: Patients with prior primary headaches (migraine, tension-type) may experience more headache symptoms if they develop a tumor 5, 6

Critical Red Flags for Your Clinical Scenario

In your patient with worsening headaches when laying down or bending over, these positional features are concerning for increased intracranial pressure and warrant urgent neuroimaging. 3

Key warning signs that distinguish secondary headache from primary headache disorders include:

• Significant change in prior headache pattern 3
• Worsening with bending over (present in 32% of brain tumor headaches) 3
• Positional worsening when lying down 3
• Nausea or vomiting (present in 40% of cases) 3
• Abnormal neurologic examination 3
• Development of new focal neurological deficits 7

Important Clinical Pitfalls

The major pitfall is assuming that headaches must be constant or have "classic" features to indicate a brain mass—this is false. 4, 3, 6

• Brain tumor headaches often satisfy diagnostic criteria for primary headache disorders like migraine or tension-type headache, potentially causing clinicians to miss the underlying tumor 6
• The distinction between primary and secondary headache disorders is not clear-cut in patients with brain tumors 6
• Headaches can be intermittent and may even be absent despite significant mass effect 2

Diagnostic Approach for Your Patient

Given the positional worsening (lying down, bending over) and previous treatment failure with metoclopramide and ketorolac, this patient requires urgent brain MRI with and without contrast to exclude a mass lesion or other cause of increased intracranial pressure. 7

• MRI is the imaging modality of choice for suspected intracranial mass lesions 7
• The clinical history of short duration with development of symptoms within weeks is typical for brain metastases 7
• Mass lesions inevitably develop other symptoms and signs besides headache, which must be actively sought 5

Do not delay imaging based on the absence of "classic" brain tumor headache features—positional worsening alone is sufficient indication for urgent neuroimaging. 4, 3