# Raised intracranial pressure in cancer: recognition, urgent scan, dexamethasone and referral

Source: https://onco.cc/protocols/raised-intracranial-pressure/  
OnCo record `raised-intracranial-pressure` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Cancer in or spreading to the brain can raise the pressure inside the skull. A headache that is worse in the morning or on coughing, being sick without feeling sick, new confusion, a fit or a change in vision needs a same-day call to your cancer team. Usually a brain scan is done and a steroid called dexamethasone is started to reduce the swelling, then lowered as soon as it can be.

## Summary

Raised intracranial pressure in cancer is usually from brain metastases or a primary brain tumour with surrounding oedema, or a bleed into or around a tumour. The Scottish Palliative Care Guidelines list a headache gradually increasing, classically worse in the morning and on coughing, sneezing or bending, vomiting often without nausea, visual disturbance, dizziness, personality change and seizures; signs (raised blood pressure, altered consciousness, ocular palsies, papilloedema) are often late. Management there: urgent CT brain may be necessary; a trial of corticosteroids with gastroprotection, dexamethasone 8 to 16 mg immediately, then 4 to 8 mg twice daily with the second dose before 2 pm, stopped promptly if there is no benefit and reduced gradually in responders; raise the head of the bed; stop anticoagulants if a bleed is suspected; analgesia and antiemetics (ondansetron); referral to oncology and consideration of neurosurgery.

The Congress of Neurological Surgeons (2019, Level 3) recommends steroids for temporary relief of symptoms from raised pressure, a starting dose of 4 to 8 mg/day of dexamethasone for mild symptoms and 16 mg/day or more for severe symptoms, dexamethasone as the steroid of choice, and tapering as rapidly as tolerated; it finds insufficient evidence for steroids in people without symptoms or mass effect. The trial behind the lower dose (Vecht 1994) found 4 mg/day gave the same improvement at one week as 16 mg/day, with fewer toxic effects, in people without signs of impending herniation. NICE NG122 (lung cancer) offers dexamethasone for symptomatic brain metastases, reduced to the minimum dose that keeps symptoms controlled. EANO-ESMO 2021 could not be read.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: raised ICP; cerebral oedema from brain metastases; brain swelling in cancer; peritumoral oedema; dexamethasone for brain metastases
- Tags: protocol; acute-oncology; oncological-emergency

## Connected records

- protocols: [Acute oncology telephone triage: the 24-hour helpline and the UKONS red, amber and green grading](https://onco.cc/protocols/acute-oncology-telephone-triage/), [Metastatic spinal cord compression: recognition, MSCC coordinator, MRI, dexamethasone, radiotherapy and surgery](https://onco.cc/protocols/metastatic-spinal-cord-compression-emergency/)
- cancers: [Brain and spinal cord tumours (all types)](https://onco.cc/cancers/brain-tumours/), [Brain metastases (secondary brain tumours)](https://onco.cc/cancers/secondary-brain-tumours/), [Glioma & glioblastoma](https://onco.cc/cancers/glioblastoma/)
- technologies: [CT (computed tomography)](https://onco.cc/technologies/ct/), [MRI](https://onco.cc/technologies/mri/), [Palliative radiotherapy](https://onco.cc/technologies/palliative-radiotherapy/)
- drugs: [Dexamethasone](https://onco.cc/drugs/dexamethasone/), [Ondansetron](https://onco.cc/drugs/ondansetron/)
- institutions: [National Institute for Health and Care Excellence](https://onco.cc/institutions/nice/)
- terms: [Brain metastases (intracranial disease)](https://onco.cc/terms/brain-metastases/), [Stereotactic radiosurgery (SRS)](https://onco.cc/terms/stereotactic-radiosurgery/), [Whole-brain radiotherapy (WBRT)](https://onco.cc/terms/wbrt/)

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