The incidence and clinical features of headache in 60 children, aged 5 to 18 years, with brain tumors were determined and compared to the pattern of primary headaches in 50 children (migraine without aura (25) and tension-type headaches (25)), in a study at the University of Padua, Italy. In the group with brain tumors (supratentorial in 17 and infratentorial in 43), headache was the first symptom in 27% and the only presenting feature in 10%. Mean time interval from onset of headache to diagnosis of tumor was 3 months for infratentorial and 17 months for supratentorial tumors. The incidence of headache was significantly higher in patients with infratentorial tumors (91%) than with supratentorial tumors (59%). Tumor histology and specific localization showed no correlation with headache patterns. Compared to primary, migraine and tension headaches, secondary tumor headaches were associated with a significantly higher incidence of projectile vomiting (51% v 22%), nocturnal or morning onset (47% v 18%), lack of triggering factors (73% v 22%), and failure of relieving factors such as rest and sleep (77% v 20%). Nausea, photophobia, and phonophobia were infrequent symptoms with brain tumors. 
COMMENT. The distinctive features of brain tumor-related headaches include morning or nightly onset, projectile vomiting, and lack of triggering or relieving factors. Although brain tumor is an infrequent cause of childhood headache, in patients with headache of recent onset, having these specific features, neuroimaging is warranted. Brain imaging indications in children with headaches are discussed in Progress in Pediatric Neurology III, PNB Publ, 1997;pp185, 167; and vol II, 1994;pp164-6).