Discussion about 2 cases of intractable headache from brain tumor in which opioids were effective and a hypothesis regarding the underlying mechanism

Abstract

Headaches caused by metastatic brain tumors result from dural tension and traction of the sites of nociceptive nerves that originates from displacement of cerebral vessels and intracranial hypertension caused by the tumor. Causes of such headaches also include meningeal irritation resulting from intrathecal dissemination of tumor and carcinomatous meningitis.Treatment of headaches resulting from intracranial hypertension involves alleviation of cerebral edema and reduction of intracranial pressure using hyperosmolar therapy and steroid administration, but treatment is often complicated by a lack of pressure reduction. We encountered 2 cases of headaches with intracranial hypertension that did not improve following hyperosmolar therapy and steroid administration, but resolved with increased opioid dose.In cases where intracranial pressure does not decrease, or for headaches attributed to direct stimulus of intracranial nociceptive nerves rather than intracranial hypertension, attempts to treat the patient with initiation or increased dosage of opioids may prove effective from a clinical standpoint.