Srinivas College of Pharmacy, Mangalore, Karnataka, India –574143
Although chronic migraine is a very common neurological condition, physicians should look for secondary causes of headaches when unusual or red-flag symptoms appear[1]. We describe the case of a 33-year-old female patient who had a history of migraine-like headaches. Her headache pattern abruptly changed, becoming more severe, worsening in her posture, and not responding well to analgesics. Neuroimaging was performed as a result of these alarming characteristics, and the results surprisingly showed a left tentorial meningioma. A distinct extra-axial, dural-based enhancing mass adjacent to the left cerebellar hemisphere was seen on MRI. It was accompanied by a modest mass effect and considerable perilesional edema. A WHO Grade I meningothelial meningioma was confirmed by histological analysis after the patient had a left retromastoid craniotomy with total tumour removal. This example highlights the significance of identifying variations from a patient's regular headache profile and shows how secondary cerebral disease can pass for chronic migraine[2][3]. Even though they are uncommon, tentorial meningiomas can just cause headaches until a significant mass effect appears[4]. In this instance, prompt diagnosis and effective surgical care were made possible by early detection of red-flag symptoms. When headache symptoms change, don't improve with treatment, or show signs of elevated intracranial pressure, clinicians should keep a high index of suspicion and seek appropriate neuroimaging[5][6].
One of the most prevalent neurological conditions is migraine, which primarily affects women and young adults. It is usually diagnosed clinically, and in patients with a consistent and distinctive pattern of symptoms, routine neuroimaging is frequently not required. However, in order to rule out secondary causes of headache, the existence of atypical features—such as persistent worsening, new neurological impairments, or poor response to previously effective therapy—should urge additional assessment.[10] These "red-flag" symptoms—such as persistent vomiting, positional deterioration, or a departure from the patient's typical headache profile—are crucial clues that neuroimaging may be necessary.
Meningiomas account for approximately one-third of all cases, making them one of the most common primary intracranial tumors. Meningiomas are common, but because of their slow growth, many of them stay asymptomatic for extended periods of time. Usually, symptoms don't appear until the tumour grows to a considerable size or starts to have a substantial effect on nearby brain structures.[11] Only 2-3% of all cerebral meningiomas are tentorial meningiomas, making them comparatively uncommon. These tumours, which originate from the tentorium cerebelli, may cause nonspecific or subtle symptoms such occipital headache, dizziness, imbalanced gait, or impairment of the cranial nerve.[12] Early detection is crucial to avoid complications like brainstem compression or obstructive hydrocephalus because of their position in the posterior fossa, a site where even small masses can have major clinical repercussions.
The majority of migraine diagnoses are based on clinical criteria, and imaging is usually not done if there are no alarming symptoms. However, when symptoms overlap, it can be difficult to differentiate basic headache diseases from secondary causes. This emphasises how crucial it is to identify warning indicators that differ from a patient's typical course. Timely imaging in these situations can identify underlying structural abnormalities that could go unnoticed otherwise.[13][14]
This case demonstrates how a left tentorial meningioma was discovered by paying close attention to unusual headache symptoms in a patient who was thought to have recurrent migraines. In order to ensure that potentially dangerous cerebral pathology is not missed, it highlights the necessity of increased clinical attention and encourages the use of neuroimaging when red-flag symptoms appear.[13][14]
CASE PRESENTATION:
PATIENT INFORMATION:
A 33-year-old female patient complained of a headache that had been worsening since a week, and was very unusual from her typical migraine pattern. The headache had a progressive course, a moderate to severe severity, and a subtle commencement. Interestingly, the discomfort was worse when lying flat and was accompanied by recurrent vomiting and sporadic light headedness. Analgesics had previously worked well for the patient's migraine attacks, but she reported a poor response to them. These characteristics were deemed red-flag symptoms indicative of a secondary headache disease, especially positional deterioration, escalation in intensity, and accompanying vomiting.[1-3]
The patient had no known systemic disease, no history of trauma, seizures, or focal neurological abnormalities, and no major prior medical history.
PHYSICAL EXAMINATION:
No localised neurological impairments were found during the neurological evaluation, which was unremarkable. At the time of assessment, vital signs were stable.
INVESTIGATIONS:
A distinct, extra-axial dural-based mass was seen in the left infratentorial compartment, next to the left cerebellar hemisphere, according to magnetic resonance imaging (MRI) of the brain. The lesion was around 3.9 × 2.8 × 3.6 cm in size. With uneven post-contrast enhancement, it showed hyperintense on T2-weighted and FLAIR sequences and iso- to hypointense on T1-weighted images. The fourth ventricle was partially effaced due to minor mass effect and significant perilesional edema.
The left straight sinus narrowed on magnetic resonance venography, most likely as a result of the tumor-related mass effect. A tentorial meningioma was strongly suggested by the dural attachment, distinctive signal intensity, contrast enhancement pattern, and related mass effect.
Impression: Tentorial meningioma on the left.
Fig 1 and 2: Contrast-enhanced MRI brain (axial and sagittal view) showing a left tentorial extra-axial mass with homogeneous enhancement at different axial levels, suggestive of left tentorial meningioma.
The brain's post-operative computed tomography (CT) showed the anticipated post-surgical alterations and showed no signs of severe cerebral haemorrhage or residual bulk.
The most prevalent benign subtype of meningioma, meningothelial meningioma (WHO Grade I), was confirmed by histopathological testing, which included biopsy and frozen section analysis. The tumour showed no unusual or malignant characteristics, and its low mitotic activity and non-elevated Ki-67 proliferation index were compatible with a benign biological behaviour.
MANAGEMENT:
Under general anaesthesia, the patient had a left retromastoid craniotomy and the left tentorial convexity meningioma removed. Simpson Grade I/II, which is linked to low recurrence rates in benign meningiomas, was attained with complete tumour excision.[12]
The tumor's tentorial placement necessitated careful microsurgical dissection because of its close closeness to the cerebellar structures and venous sinuses, which is consistent with the surgical difficulties sometimes associated with tentorial meningioma.[7-9]
In the neurosurgical critical care unit, the patient maintained haemodynamic stability, with sufficient pain management, and had no new neurological impairments. Imaging obtained after surgery verified that the tumour had been successfully removed and that there was no remaining lesion. After that, the patient was released on standard postoperative medication, and remained clinically stable on follow-up.
Fig 3: Post-operative contrast-enhanced MRI brain showing complete excision of the left tentorial meningioma with no residual enhancing lesion.
DISCUSSION:
This case demonstrates how an underlying structural cerebral abnormality can be identified when a patient with a persistent headache exhibits red-flag symptoms. A change in headache pattern, positional worsening while resting flat, new-onset vomiting, subacute progression, and a poor response to previously successful migraine medication were among the warning indicators that were apparent even though the patient originally displayed symptoms indicative of migraine. Because positional headache aggravation frequently indicates elevated intracranial pressure, it is very serious and requires immediate assessment.[12]
Previous research has highlighted that headache continues to be the most prevalent initial symptom of intracranial tumours, especially those in the posterior fossa, where space constraints may cause early pressure effects on nearby tissues.[15][16] Forsyth and Posner, in their study showed that the progressive nature, morning predominance, positional deterioration, and relationship with vomiting of headaches linked to brain tumours frequently distinguish them from primary headache syndromes, all of which were present in this patient.[16] Kurtis and Vázquez also noted that tumours in the posterior fossa often cause nonspecific headache symptoms, which might delay diagnosis if warning signs are ignored.[15]
When headache characteristics differ from a patient's baseline pattern or are accompanied by red-flag symptoms, neuroimaging is regularly recommended by guidelines and expert reviews on headache evaluation.[1-3] According to Do et al., treatment resistance, vomiting, and positional headache worsening are some of the best indicators of secondary headache disorders.[2] The significance of early imaging is highlighted by the fact that symptoms of meningiomas, particularly tentorial lesions, may be mild until a substantial mass effect appears.[7][9]
In order to avoid missed or delayed diagnosis of intracranial tumours, clinical attention and adherence to red-flag criteria are crucial, as this case demonstrates. This patient's early diagnosis and rapid neuroimaging enabled fast surgical intervention, which had a successful outcome.
Only two to three percent of intracranial meningiomas are tentorial meningioma.[8] Because they grow slowly, symptoms might not show up until there is a noticeable bulk effect. Because even very tiny tumours might compress the cerebellum, brainstem, or venous sinuses, resulting in increased intracranial pressure and neurological impairment, lesions in the posterior fossa are especially worrying. The patient's MRI showed a mass effect on the straight sinus, which probably led to the development of symptoms and venous congestion.
The size of the lesion, concomitant perilesional edema, and mass effect in this instance substantially linked with the patient's clinical presentation, despite the fact that many meningiomas are discovered by accident and remain asymptomatic. When meningiomas are discovered, these characteristics indicate a symptomatic etiology rather than an accidental discovery, highlighting the necessity of individualized clinical correlation.
Missed or delayed diagnosis of cerebral disease may result from delayed neuroimaging in individuals whose headaches are thought to be primary. According to studies, tumor-related headaches frequently have characteristics that set them apart from primary migraine, including progressive course, positional deterioration, and connection with vomiting—all of which were evident in this instance.[15][16] Red-flag symptoms greatly raise the risk of subsequent headache problems and call for immediate imaging, according to reviews and clinical guidelines.[1-3] Early imaging enables prompt treatments and better results in posterior fossa lesions, but delayed diagnosis may lead to consequences including ataxia, cranial nerve impairments, or obstructive hydrocephalus.[7-9][12] This example lends credence to the body of research supporting early neuroimaging when a patient's headache features change from their usual pattern.
CONCLUSION:
This case emphasises how crucial it is to be clinically vigilant while treating patients with persistent migraines, especially when their headache symptoms change. Red-flag signs, such as changes in pattern, intensity, and responsiveness to therapy, prompted immediate MRI, which resulted in the unexpected discovery of a large left tentorial meningioma. Early detection avoided possible problems related to posterior fossa lesions and allowed for effective surgical intervention with good neurological recovery.
This instance highlights the wider therapeutic consequence that major secondary pathology can be concealed by primary headache syndromes, which goes beyond the treatment of individual patients. To prevent diagnostic delays, adherence to red-flag criteria and a low threshold for neuroimaging in unusual presentations are crucial. When treating headache patients with unusual characteristics, clinicians should have a high index of suspicion in order to ensure early diagnosis and the best possible outcomes through prompt and appropriate management.
LEARNING POINTS:
PATIENT CONSENT:
Written informed consent was obtained from the patient for publication of this case report and the accompanying anonymized radiological images. Efforts have been made to ensure that the patient’s identity remains confidential.
REFERENCES
U Y Fareena Faizal, Dhanya T Bappanad, Unexpected Discovery of a Left Tentorial Meningioma During Evaluation for Chronic Migraine: Significance of Red-Flag Symptoms, Int. J. of Pharm. Sci., 2026, Vol 4, Issue 1, 1109-1115. https://doi.org/10.5281/zenodo.18213615
10.5281/zenodo.18213615
