Neurology · Easy
This case is fictional and exists for study. It describes no real patient.
68 years · female
A 68-year-old female presents to the acute medical clinic with a 2-week history of a persistent, severe right-sided temporal headache. She reports pain in her jaw when chewing solid food and severe discomfort when brushing her hair over the right side of her head. Over the past 24 hours, she has experienced two transient episodes of vision loss in her right eye, described as a curtain coming down over her visual field. She has a background history of polymyalgia rheumatica. Physical examination reveals a prominent, thickened right temporal artery that is tender to palpation with reduced pulsation. Fundoscopy is currently normal.
Vital signs
- HR
- 78 bpm
- BP
- 138/84 mmHg
- RR
- 16/min
- Temp
- 37.2 °C
- SpO₂
- 98%
Examination findings
- Thickened, tender right temporal artery with diminished pulse
- Scalp tenderness on right temporal region
- Normal visual acuity bilaterally at time of examination
Investigations
| Erythrocyte Sedimentation Rate (ESR) | 88 mm/hr | reference: 0-20 |
| C-reactive protein (CRP) | 46 mg/L | reference: 0-5 |
| Haemoglobin | 11.2 g/dL | reference: 12.0-15.5 |
Question 1 of 3
What is the most likely diagnosis?
Giant cell arteritis (GCA) is a systemic vasculitis occurring almost exclusively in patients over 50 years. Key clinical features present here include temporal headache, scalp tenderness, jaw claudication, transient visual disturbances (amaurosis fugax), and markedly elevated inflammatory markers (ESR and CRP). Trigeminal neuralgia causes brief, electric shock-like facial pain triggered by light touch. Migraine with aura typically presents in younger individuals with episodic visual phenomena (scintillating scotomas) rather than transient monocular blindness. Tension-type headache presents as a band-like bilateral pressure pain without jaw claudication, scalp tenderness, or elevated inflammatory markers.
Teaching point: New temporal headache, scalp tenderness, jaw claudication, and elevated ESR in an older adult strongly indicate giant cell arteritis.
Question 2 of 3
Which of the following is the most appropriate next step in management?
When giant cell arteritis is clinically suspected, high-dose corticosteroid therapy (e.g., high-dose oral prednisolone or IV methylprednisolone if visual symptoms are present) must be started immediately to prevent permanent blindness. Treatment should never be delayed while awaiting temporal artery biopsy; histological findings remain diagnostic for 1–2 weeks after initiating steroids. Non-contrast CT head is indicated for acute head trauma or subarachnoid haemorrhage, not GCA. Sumatriptan is indicated for migraine and cluster headaches and has no role in treating GCA.
Teaching point: Immediate administration of high-dose corticosteroids is mandatory when giant cell arteritis is suspected to prevent irreversible visual loss.
Question 3 of 3
Which investigation is required to definitively confirm the diagnosis?
Temporal artery biopsy is the definitive gold-standard investigation to confirm giant cell arteritis. Histopathology typically demonstrates granulomatous inflammation, multinucleated giant cells, and disruption of the internal elastic lamina. CT head and lumbar puncture are performed when evaluating subarachnoid haemorrhage or idiopathic intracranial hypertension. MRA brain visualizes intracranial vessels but is not the standard confirmatory test for GCA compared to biopsy or temporal artery ultrasound.
Teaching point: Temporal artery biopsy is the gold-standard confirmatory investigation for giant cell arteritis.
Key learning points
- Headache red flags in older patients include new-onset focal headache, jaw claudication, scalp tenderness, and transient visual loss.
- Giant cell arteritis requires immediate initiation of high-dose corticosteroids to prevent irreversible ischaemic optic neuropathy.
- Temporal artery biopsy provides definitive pathological confirmation and should be arranged promptly, but must never delay steroid administration.
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