**4. Signs and symptoms**

### A. Headache

Headache occurs commonly in all brain tumor patients. The headache is said to develop in the temporal and the spatial, relation to the neoplasm and resolves 7 days of surgical removal or treatment with corticosteroids [48].

Headache in pituitary brain tumor

The presence of headache has been shown to be more highly associated with family history than the tumor size [47].

Headache in pediatric brain tumor

Headache appears to be the most common presenting symptom (41% of patients in some studies). It tends to occur with other symptoms such as vomiting, unsteadiness, behavioral problems, and cranial nerve palsies, and most commonly nocturnally (or) in the early morning [49].

Mechanism of headache in brain tumor

The mechanism of headache in brain tumors may include the traction on vascular structure, cranial or central sensitization through neurogenic inflammation as well as the component of central sensitization through trigeminovascular afferents on the meninges and the cranial nerves [50].

B. Nausea and vomiting

Nausea and vomiting occur when the chemo trigger zone in the area postrema, located on the floor of the fourth ventricle is stimulated. Raised intracranial pressure leads to vomiting. It can also occur in the absence of elevated intracranial pressure in brain stem tumors involving the nucleus solitarius [51].

#### Mechanism of vomiting

Nausea and vomiting are highly conserved responses and the survival advantages in survival vertebrates. Vomiting is primitive, low-threshold, brain stem response that allows the human to purge the gastrointestinal tract of orally consumed noxious substances. Vomiting is multidimensional having a higher cognitive brain center, emotions, and interoceptive domains is more common disabling, and more difficult to control than vomiting [52].

#### C. Altered mental status

Mental and cognitive abnormalities may be specific, or nonspecific. Specific findings include aphasia, agnosia, abulia, alexia, or apraxia. In about 16–34% of patients, the symptoms for brain tumor patients include irritability, change in personality, emotional liability, forgetfulness, lack of enthusiasm or spontaneity, and slowed response progressing apathy and lathery [53].
