Learn which symptoms should prompt brain imaging in primary care, how glioma classification has changed and when to refer to a neuro-oncology team.

Author: Sara O. Thompson

Medically reviewed by:
Kaylyn D Sinicrope, MD

Published: November 6, 2026

Brain tumors are uncommon, but primary care providers (PCPs) are often the first to suspect one. A Norton Neuroscience Institute continuing medical education opportunity recently outlined brain tumor red flags for PCPs, including what to watch for, what has changed in treatment and when to refer.

Kaylyn D. Sinicrope, M.D., neuro-oncologist with the Norton Healthcare Brain Tumor Center, presented this update at the 2026 Neuroscience Symposium.

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When to image

A single, isolated symptom rarely warrants a brain tumor workup. Headache alone, for example, has a positive predictive value of about 0.1%. The picture changes when symptoms cluster or progress. Consider an MRI of the brain when you see early signs including:

• Adult-onset seizures with no epilepsy history or provoking factor (the single most predictive symptom)
• Neurological deficits that worsen over weeks to months, such as progressive weakness
• Headache plus other neurological symptoms, such as confusion or word-finding trouble
• Headache with signs of increased intracranial pressure: worse when lying down, pain that wakes the patient from sleep, vomiting, or worsening with coughing or bearing down

Tumors pressing on the inferior frontal lobe can mimic progressive depression or personality change, so keep them in mind when psychiatric symptoms are new and worsening.

In patients with a cancer history, any new neurological symptoms raise concern for brain metastases, the most common intracranial tumor. Lung cancer, breast cancer, melanoma and renal cell carcinoma are among the most frequent sources. Order a brain MRI with and without contrast when possible. If MRI isn’t an option, use CT with contrast. Noncontrast imaging can miss tumors.

What’s changed in classification and treatment

• Molecular classification. Since 2021, central nervous system (CNS) tumor diagnosis combines histology with molecular sequencing. Isocitrate dehydrogenase (IDH) status is a key divider: Glioblastoma is now defined as IDH wild type, while IDH-mutant tumors have a different prognosis and behavior.
• Vorasidenib. In the INDIGO trial of Grade 2 IDH-mutant gliomas, this IDH inhibitor roughly doubled time to tumor progression (about 27 months versus 11). The most common finding is a mild aspartate aminotransferase and alanine aminotransferase elevation.
• Dordaviprone (Modeyso). This drug is for recurrent diffuse midline glioma with the H3 K27M mutation. It showed a 22% response rate, notable for CNS tumors, and has Food and Drug Administration fast-track approval. Watch for QTc prolongation, especially in patients also taking ondansetron.
• Glioblastoma. Standard care is maximal safe resection, then temozolomide with radiation. Tumor treating fields may be added based on patient preference.
• Brain metastases. Care has shifted from whole brain radiation toward stereotactic radiosurgery to reduce neurocognitive effects. A newer option places GammaTile® cesium-131 collagen implants during surgery, starting radiation immediately. In a Phase 3 trial, local recurrence was 1% with the implant versus 12% with standard radiosurgery.

What you may see in clinic

• Meningioma and hormones. Progesterone-only contraception, especially the Depo-Provera injection, may accelerate tumor growth in patients with a known meningioma. Consider alternatives or increase surveillance if the patient declines. Data on combined oral contraceptives, patches, rings, low-dose IUDs and copper IUDs are limited or reassuring. Hormones don’t appear to affect glioma growth.
• Incidental meningioma. For asymptomatic patients, annual imaging is reasonable, with a shorter interval if there is a cancer history. Growth is most likely in the first five years.
• Steroids. Taper when possible. Long-term use can cause hyperglycemia, myopathy, avascular necrosis and adrenal insufficiency. If lymphoma is possible, leave steroids to the specialist to protect diagnostic yield.
• Seizure prophylaxis. Don’t start anti-seizure medication without a history of seizures. Levetiracetam and lacosamide are preferred over enzyme-inducing agents.
• Blood clots. Anticoagulation is safe in patients with brain tumors unless there is a recent bleed.
• Survivorship. Fatigue, cognitive complaints and dizziness are common years after treatment. Endocrine issues can appear years after pituitary radiation, and standard psychotropic medications are safe.

When to refer

Patients with a suspected or confirmed brain tumor do best with a multidisciplinary neuro-oncology team. Most can be seen through urgent referral within a day or two. Send patients to the emergency department if they’re acutely unwell.

Norton Healthcare Brain Tumor Center

The Norton Healthcare Brain Tumor Center is a collaboration of Norton Neuroscience Institute and Norton Cancer Institute and offers same-day appointments for newly diagnosed patients. This multidisciplinary program offers the latest in treatment options for brain and spinal cord tumors.