GPAtlas🧭 When to suspect
Brain and central nervous system tumours are uncommon, but they are among the cancers most often diagnosed late – early features are non-specific and overlap heavily with far commoner benign conditions such as migraine, tension-type headache, low mood and vestibular disorders.
In adults, secondary (metastatic) tumours – most often from lung, breast, melanoma, renal and colorectal primaries – are more common than primary brain tumours; the commonest primary malignant tumour is glioblastoma.
The recognition principle in adults is that isolated headache is a poor predictor (low positive predictive value).
What should raise concern is a progressive, subacute loss of central neurological function, and "headache PLUS" or "cognitive PLUS" combinations – headache or confusion accompanied by:
• Focal weakness
• Visual or speech disturbance
• Personality change
• A seizure
The most predictive single presentations are:
• New-onset seizure
• A new focal neurological deficit
• Unexplained cognitive or personality change
In children and young people, presentation is age-dependent and headache is frequently absent. These dominate:
• Persistent vomiting (classically on waking)
• Unsteadiness
• Abnormal eye movements
• Behaviour change
Take parental concern and repeated attendances seriously – three or more presentations for the same unexplained symptom should prompt reassessment rather than reassurance.
| Suspect in adults |
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• Progressive, subacute loss of central nervous system (CNS) function over days to weeks – the key NICE referral trigger. |
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• New-onset seizure – a first unprovoked seizure at any age. |
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• A new, progressive focal deficit – limb weakness, dysphasia, visual field loss or ataxia. |
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• Unexplained cognitive decline or personality change – frontal tumours are easily mistaken for depression or early dementia. |
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• Headache PLUS – new or progressively severe headache with raised-ICP features (worse on waking, lying down, coughing or straining; with nausea/vomiting) or with any neurological symptom. |
| Suspect in children & young people |
|---|
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• Persistent or recurrent vomiting, classically early-morning or on waking. |
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• New problems with balance, coordination, gait or abnormal eye movements. |
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• Behaviour, personality or developmental change (or lethargy in the very young). |
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• Abnormal head position (head tilt, wry neck) or, in infants, an increasing head circumference. |
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• Persistent/recurrent headache (school-age), or delayed/arrested puberty or growth (teenagers). |
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