Severe headache and jaw pain (326/1700)

A 54 yo lady presents with sudden, severe pain in the left half of her skull. She also complains of
pain around her jaw. What is the next likely step?
a. CT
b. MRI
c. Fundoscopy
d. ESR
e. Temporal artery biopsy




























answer: D

GCA/TEMPORAL ARTERITIS

Classification Criteria for GCA: Diagnosed if 3 or more of the 5 criteria present

1. Age at onset ≥50

2. New headache Often temporal

3. Temporal artery abnormality Temporal artery tenderness or decreased pulsations, not due to arteriosclerosis

4. Elevated ESR ESR ≥50 mm/h

5. Abnormal artery biopsy Mononuclear cell infiltration or granulomatous inflammation, usually with multinucleated giant cells

Signs and Symptoms

• new onset temporal headache ± scalp tenderness due to inflammation of involved portion of the temporal or occipital arteries

• sudden, painless loss of vision and/or diplopia due to narrowing of the ophthalmic or posterior ciliary arteries (PCA more common); can affect both eyes

• tongue and jaw claudication (pain in muscles of mastication on prolonged chewing)

• PMR (proximal myalgia, constitutional symptoms, elevated ESR) occurs in 30% of patients

• aortic arch syndrome (involvement of subclavian and brachial branches of aorta result in pulseless disease), aortic aneurysm ± rupture are late complications

Treatment

• if suspect GCA, immediately start high dose prednisone 1 mg/kg in divided doses for 4 wk, and then tapering prednisone as symptoms resolve; highly effective in treatment and in prevention of blindness and other vascular complications

• consider low dose ASA

Prognosis

• increased risk of thoracic aortic aneurysm and aortic dissection

• yearly CXR ± abdominal U/S as screening