In this section, the three consultations continue with the patients being asked about any additional symptoms that they may have been experiencing. Consider the additional features of each patient’s headache and assess which patient you are most concerned about.

Click on each of the names to watch the next part of each patient’s consultation.

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Ella Gillberg

Ella described a long history of migraine. They have become more frequent, occur in the morning and are a cause of great worry.

Arthur Kilroy

Arthur described a mild non-specific headache.

Sarah Lewis

Sarah described the onset of non-specific headaches for the past 2-3 months. They have been getting worse over that time both in severity and frequency.

Summary of symptoms

Nausea and vomiting

Feeling nauseous is a common presenting symptom for patients with brain tumours, however it is rare for it to be the only presenting symptom. Experiencing nausea and vomiting is common for individuals with raised intracranial pressure and for migraine
sufferers, so should be considered alongside any presentation or history of headaches. Nausea and vomiting are an uncommon presenting symptom for a brain tumour and would tend to develop quickly over less than a week in association with raised intra-cranial
pressure.

Dr Sarah Taylor, GatewayC GP Lead, discusses these symptoms with Professor Catherine McBain, Honorary Professor in Cancer Sciences.

Nausea or vomiting associated with a brain tumour:

• may be worse in the mornings and get better during the day as the tumour may cause a build-up of pressure in the skull overnight, but this begins to drain during the day when in an upright position
• may get worse if you suddenly change position (e.g. from sitting or lying to standing)
• may continue for more than a week, on most days, with no sign of getting better
• may be accompanied by hiccups
• are usually accompanied by other common brain tumour symptoms, such as a headache or a change in vision.

Nausea and vomiting are more frequent presenting features of brain tumours in children than in adults. There is more information on the symptoms of brain tumours in children in the ‘Paediatric brain tumours’ section of this course.

Visual changes

Brain tumours can cause changes to an individual’s vision, such as incidences of blurred or double vision, abnormal eye movements and restricted fields of vision. It is therefore important to ask directly about any clumsiness, accidents or near misses
as these can indicate visual field loss.

Dr Sarah Taylor discusses visual field loss tests and the role of optometrists with Lorcan Butler, The Brain Tumour Charity’s Optical Engagement Manager.

Key Points:

• Visual field loss can be one of the early signs of a brain tumour. However, individuals frequently don’t notice a deficit in visual fields as the other eye will compensate
• Full optometry assessments can be helpful in diagnosing brain tumours, although normal results do not exclude a brain tumour
• Papilloedema warrants urgent investigation for causes of raised intracranial pressure

According to the guidelines set out by The College of Optometrists, if an optometrist suspects papilloedema, they should make an urgent referral (within 24 hours) to an ophthalmologist, who will then ​confirm the diagnosis and refer the individual
for a CT scan and/or MRI scan to determine the cause. Papilloedema can be caused by Idiopathic Intracranial Hypertension (IIH), meningitis, hydrocephalus, brain clots and brain tumours.

Patient assessment

• Ella’s symptoms are still typical of a migraine
• Arthur has no nausea, vomiting or visual disturbance, but still has worrying symptoms
• Sarah does not describe any visual disturbance, but has noticed that she is more clumsy and accident-prone which may be due to an undiagnosed visual change

Additional resources

Link: Nausea and dizziness, The Brain Tumour Charity
Link: Nausea: a review of pathophysiology and therapeutics, Therapeutic Advances in Gastroenterology 9:1 (2016)
Link: Annex 4 Urgency of referrals, The College of Optometrists
Link: Eye tests, The Brain Tumour Charity