Synopsis
Recognise headache patterns that indicate intracranial mass effect or another neurological emergency, image before unsafe lumbar puncture, relieve tumour oedema with proportionate corticosteroid and coordinate neurosurgical, radiotherapy and comfort decisions.
- Ask about onset speed, progression, morning or positional pattern, cough or strain, vomiting, seizure, cognition, focal symptoms and analgesic or steroid exposure.
- First-line examination records consciousness, pupils, cranial nerves, power, sensation, coordination, gait, fundoscopy when feasible and vital signs.
- Urgent non-contrast CT is first-line for acute haemorrhage, major mass effect and hydrocephalus; contrast MRI is the gold-standard definition of brain tumour and metastatic burden after stabilisation.
- Never perform lumbar puncture before excluding unsafe raised intracranial pressure when papilloedema, focal deficit, seizure or altered consciousness is present.
- For symptomatic tumour-related oedema, dexamethasone commonly starts at 4 to 8 mg daily for moderate symptoms and up to 16 mg daily for severe pressure features under specialist guidance.
- Give dexamethasone early in the day where possible, monitor glucose and mental state and use the lowest effective dose with a written taper linked to surgery or radiotherapy.
- Definitive treatment may be neurosurgical resection, cerebrospinal-fluid diversion, stereotactic treatment, whole-brain radiotherapy or systemic therapy according to tumour, function and goals.
- Do not start antiseizure medication solely as prophylaxis in every seizure-naive brain-tumour patient; treat an actual seizure through the neurological pathway.
- The gold-standard plan connects imaging, steroid goal and taper, definitive treatment, seizure rescue, analgesia and escalation ceiling while preserving comfort if intervention is declined.
Key red flags
Thunderclap onset, meningism, fever, collapse or new neurological deficit requires immediate haemorrhage, infection and vascular assessment.
Progressive morning or positional headache with vomiting, papilloedema, focal signs or cognitive change suggests raised intracranial pressure.
Reduced consciousness, unequal pupils, extensor response or Cushing physiology is a late herniation sign and requires emergency action.
Do not perform lumbar puncture when mass lesion, obstructive hydrocephalus, papilloedema or focal deficit raises herniation risk.
New seizure or persistent postictal deficit requires urgent glucose, imaging and seizure management rather than analgesia alone.
Dexamethasone can cause severe hyperglycaemia, infection, psychosis, insomnia, gastrointestinal harm and proximal weakness and needs the lowest effective dose and taper plan.
NSAIDs and contrast require renal and bleeding review, while valproate and many sedatives require hepatic caution.
Rapid coma, unequal pupils, extensor posturing or Cushing physiology requires immediate emergency neurological management.
Investigation priorities
Document arousal, pupils, cranial nerves, fields, speech, limbs, coordination, gait and fundoscopy to identify change and localisation.
Management branches
Headache accompanies falling consciousness, new pupil change, focal deficit, repeated vomiting, seizure or late pressure signs.
- Call neurological and critical-care help, use ABCDE care, elevate the head about 30 degrees, maintain neutral neck and correct hypoxia, hypotension and glucose disturbance.
- Obtain urgent non-contrast CT and give dexamethasone promptly for suspected tumour oedema; use hyperosmolar treatment only through the acute specialist protocol.
- Coordinate neurosurgery, cerebrospinal-fluid diversion, radiotherapy or comfort-focused care based on pathology, reversibility, capacity and the documented treatment ceiling.