02 Nov Case Studies in Headache: Giant Cell Arteritis
By Thomas N. Ward, M.D.
Dartmouth Hitchcock Medical Center
A 67-year-old man came to a neurologist’s office as a referral from a local family practitioner. The patient’s doctor was concerned, as the patient had complained of a new headache. The headache had been present for three weeks, was mild to moderate in severity, and worse on the right side than on the left. There was no nausea, nor sensitivity to light or to sound.
The patient reported some aching in his jaw and in his tongue during meals, which was a new symptom as well. Ominously, over the last week, he had experienced three 15-minute painless episodes of visual loss in his right eye. The patient reported that he had suffered from migraines in earlier years, but they were not at all like the current headache and he had not had any for many years. Over the past three months he had lost about 20 pounds though he wasn’t dieting. He had felt generally mildly ill during this time frame and had mild discomfort in his shoulders and hips.
Upon hearing this tale, the neurologist became quite animated. He examined the patient and spent some time palpating (feeling) the man’s temples. He then sent the patient to the laboratory for blood testing and on to Radiology for a CT scan of the brain. The man was immediately started on a new medication and, when the CT scan report returned normal, a biopsy of one of the temperol arteries was performed. The headache resolved immediately. The medication controlled his symptoms. Over time, the medication was tapered, and then slowly discontinued.
New headaches that begin after age 50 generally prompt concern that they are not primary headaches (like migraine, cluster or tension-type), but have a higher likelihood of being secondary (due to an underlying cause, like a brain tumor or another ominous condition). As noted above, a CT scan was ordered because the doctor also worried about a brain tumor. In this case, however, the patient had a condition known as giant cell arteritis (GCA), also known as temporal arteritis or cranial arteritis. This illness usually begins in patients over 50 years old. The results of a blood test, called the erythrocyte sedimentation rate (ESR), are usually abnormally high.
Headache is the most common symptom in giant cell arteritis. It is a new headache, but can mimic most any type of primary headache (i.e. migraine, cluster, tension-type). It can be constant or intermittent. Aching pain with use of the jaw or tongue (called claudication) is not typical, but when present is very suggestive. Patients may have tender, inflamed, and/or thrombosed (swollen or clotted) superficial temporal arteries (blood vessels at the temple). Weight loss, fevers and malaise are common. About half the patients with GCA also have polymyalgia rheumatica (PMR), which causes aching in the shoulders and/or hips.
GCA is a medical emergency. If not adequately treated in time, the major complications include blindness and stroke. The treatment approach is to immediately start steroids, such as prednisone, and then to promptly biopsy one or both superficial temporal arteries (a minor outpatient procedure). Inflammation may actually be more widespread than in just the vessels in the head and a thorough evaluation is warranted.
GCA usually is a self-limited disease, meaning it will eventually run its course and not return. Steroid medication is very effective but has many potentially serious side effects. The dose can be slowly reduced and often discontinued after a number of months. The headache interestingly often resolves when the inflamed artery is removed for biopsy! While GCA is relatively easy to treat, it is definitely one headache condition not to be missed.