Non-Covid clinical crises: Potential brain tumour

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