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The waiting game

Non-Covid clinical crises: Potential brain tumour

Pulse’s series on how to manage non-Covid subacute problems when you’re out of your comfort zone and there’s minimal help available

The annual population incidence of a brain tumour is 0.01%. The incidence of a tumour diagnosed one year after a GP consultation for headache is 0.09%.

Here is a guide for those red flag symptoms that need urgent investigation even in the midst of a COVID-19 pandemic and which symptoms have a lower threshold for investigation but require careful monitoring.

Red flag symptoms requiring urgent investigation with the risk of tumour likely to be greater than 1% (two week referral):

  • focal neurology
  • significant alterations in consciousness, memory
  • epileptic seizure
  • history of cancer elsewhere, particularly breast, prostate or lung.

Orange flags require careful monitoring but with a lower threshold for investigation with the risk of tumour likely to be between 0.1 and 1% (discuss with neurology or order imaging if directly available and not resolving):

  • new headache where a diagnostic pattern has not emerged after eight weeks from presentation. The majority of headaches presenting to general practice will be migraine.
  • headache aggravated by exertion or Valsalva’s manoeuvre
  • headaches that have been present for some time but have changed significantly (here interpretation may be difficult)
  • new headache in a patient over 50 years of age (exclude temporal arteritis)
  • headaches that wake from sleep (but migraine and cluster headache invariably wake from sleep)
  • subtle personality change (history from partner).

Orange flags need regular fundoscopy as a minimum examination, blood tests are unhelpful. Discuss problems of incidental abnormalities with imaging with the patient as can cause significant anxieties and can be as high as 10%. MRI is the investigation of choice but it could be argued that if a tumour is of sufficient size to give headache it will be visible on CT.

Dr David Kernick is a GP with special interest in headache based in Exeter

Readers' comments (3)

  • The author should elaborate of what is meant by "focal neurology".

    Also, blood tests can be useful in orange situations namely inflammatory markers re temporal arteritis and I would contend others in subtle personality change evolving less than acutely.Sodium and calcium spring to mind.

    Also a strategic location without big size may also cause headache and CT can miss these much more readily than MR.

    History and a comprehensive exam have an integral role to play in evaluating these patients, something that I hope doesn't get overlooked as the love affair with remote consulting seems to be coming to the fore.

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  • I do not agree that prostate cancer commonly metastasises to brain. The relevant cancers are breast bronchus kidney melanoma & thyroid.

    Worth remembering that some sort of mass lesion, usually benign, is found by chance in abut a quarter of heathy people on MRI brain scan.

    Idgaf, I agree that"focal neurology' is vague, it is however common medical parlance. You could argue that all neurology is focal.

    "Subtle personality change" is similarly difficult. Hard to disentangle organic personality change, from the non-specific effects of illness.

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  • Giles- very good comments,
    I agree only I would like to add bowel cancer, endometrial cancer , leukemia , lymphoma and unfortunately prostate CA as well
    All the best for all hard working staff(dr's. nurse's , paramedic's etc)

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