Many patients present to the Emergency Department with headaches – very few (almost none) have brain tumors despite a high level of parental concern. Let’s take a look at various symptoms and how likely they are in the diagnosis of brain tumors in children.
Far and away headache is the most common symptom – but not every with a brain tumor has had them. In a review of a registry of almost 3,300 children with brain tumors 3 out of 5 children with CNS assess had chronic headaches leading up to the diagnosis. In a more recent study from Lancet Oncology the proportion of children with CNS tumors and headache was only about ⅓. In children younger than 4 only 1 out of 4 reported headache. I think that this is due to preschoolers being unable to actually articulate symptoms.
We often presume that elevated ICP causes headaches – especially that early morning headache in association with emesis. This is because of gravity. Kids lay down to sleep, fluid pressure builds up, and the vomiting centers of the CNS are activated. Oftentimes, the headache improves after throwing up. In reality, they can occur throughout the day. In a study of 200 children with brain tumors by Wilne et al. early morning or nighttime headaches were only seen in 1 in 5.
Migraines, tension headaches, post concussive symptoms and the headache associated with common illnesses (strep, URI) are all much more common than brain tumors – and many of them have headaches that can occur in multiple locations of the head. So in general, the location of the headache is less important than what else is going on.
As you can see in the above figure, the spread of symptoms is variable, and does not help you all of the time. Let’s take a look at some of these other symptoms.
In the aforementioned study by Wilne et al. it was noted that vomiting was seen in only 12% as the first presenting symptom. Vomiting seems to be more associated with posterior fossa tumors.
Seen in 10-15% of children with CNS masses.
Can be a much later finding in infants, as the sutures of the skull have yet to close. Bulging fontanelle, widely splayed sutures and increased occipital-frontal head circumference are all concerning findings. In practice I’ve seen this associated with hydrocephalus, rather than a tumor itself – unless of course you’re talking about a posterior fossa tumor, which can obstruct CNS outflow.
Signs and symptoms vary by the age of the child
- Increased head circumference
- Splayed sutures or tense fontanelle
- Head tilt/torticollis
- Loss of previously acquired developmental milestones
- Weight loss and poor feeding
- Intermittent headaches
- Nausea and vomiting
- Declining school performance
- Personality changes
- Weight loss and Anorexia