Headache Characteristics in Glioblastoma
Glioblastoma most commonly causes tension-type-like headaches (47% of cases) or classic brain tumor headaches characterized by progressive worsening, morning predominance, and association with increased intracranial pressure (42% of cases). 1
Primary Headache Phenotypes
The clinical presentation of headache in glioblastoma follows distinct patterns:
- Tension-type-like headache (TTH) is the most common phenotype, occurring in 47% of patients who present with headache, and tends to occur in older patients 1
- Classic brain tumor headache (BTH) occurs in 42% of cases and is characterized by progressive worsening over time, often with nausea, vomiting, and blurred vision from increased intracranial pressure 2, 1
- Worsening of pre-existing headache (WPH) accounts for 11% of presentations 1
- Migraine-like headache is notably absent in glioblastoma presentations 1
Clinical Features and Warning Signs
Headaches occur in approximately 50% of glioblastoma patients overall, though only 12.5% present with headache as their initial symptom. 2, 1
Key distinguishing features include:
- Progressive worsening pattern over weeks to months, reflecting the rapid growth dynamics of high-grade tumors 3, 2
- Morning predominance with improvement throughout the day (classic BTH pattern) 2
- Associated symptoms of increased intracranial pressure including nausea (88%), vomiting, and blurred vision 2, 4
- Persistent headache despite normal initial imaging may be a sentinel sign, as glioblastoma can develop rapidly (within 3.5-4 months) after normal MRI 5
Tumor-Related Factors Influencing Headache
Specific tumor characteristics affect headache presentation:
- Infratentorial location is more frequently associated with headache at onset (p=0.038) 1
- Right-sided tumors are more commonly associated with headache (p=0.013), while left hemisphere location appears protective 1
- Classic BTH is less frequently associated with other neurological signs (p<0.0001), meaning it may present in isolation 1
Important Clinical Caveats
Not all glioblastoma patients experience headache—approximately 40-50% never develop this symptom, even with large tumors and increased intracranial pressure. 2, 6 This absence of headache can delay diagnosis and should not provide false reassurance.
In the terminal phase, headache becomes less prominent (only 33% in the last 10 days of life) as decreased level of consciousness (95%) dominates the clinical picture 4. This makes pain assessment challenging and emphasizes the need for proactive symptom management with opioids (95% of patients) and NSAIDs (77%) 4.
Diagnostic Approach
When glioblastoma is suspected based on headache characteristics:
- MRI with gadolinium contrast is mandatory as the diagnostic gold standard, showing typical features of strong enhancement, central necrosis, and peritumoral edema 3, 2, 7
- Short-interval follow-up imaging (3-4 months) is critical for persistent headache with initially normal imaging, as glioblastoma can develop rapidly 5
- High-grade astrocytomas typically present with symptoms of increased intracranial pressure, seizures (20-50% of cases), or focal neurologic findings related to tumor size, location, and associated edema 3, 2