A 70-year-old patient presents with new headache, scalp tenderness, and blurred vision. Rookies may dismiss this as “migraine” or “tension headache.” But this could be temporal arteritis (giant cell arteritis, GCA) — a vasculitis that threatens permanent blindness if missed.
What Is Temporal Arteritis?
- Granulomatous vasculitis affecting medium/large arteries, especially extracranial branches of the carotid artery.
- Peak age: >50 years (rare below this age).
- Strongly associated with polymyalgia rheumatica (PMR).
Why It Matters in the ED
- Vision loss (from ischemic optic neuropathy) occurs in up to 15–20% if untreated.
- Early steroids can prevent blindness in the other eye.
- Delay in diagnosis = irreversible morbidity.
Classic Clinical Features
- New-onset temporal headache (often throbbing, localized).
- Scalp tenderness (pain when combing hair).
- Jaw claudication (pain with chewing).
- Visual symptoms: transient vision loss (amaurosis fugax), diplopia, blurred vision.
- Constitutional: fatigue, fever, weight loss.
- PMR symptoms: shoulder/hip stiffness and pain.
ED Evaluation
Labs
- ESR: usually >50 mm/hr (but may be normal).
- CRP: more sensitive; almost always elevated.
- CBC: normocytic anemia, thrombocytosis common.
Imaging / Biopsy
- Temporal artery biopsy = gold standard (arranged outpatient, not ED).
- Ultrasound/MRI of temporal arteries sometimes used.
Rookie pearl: Never wait for biopsy to start steroids if suspicion is high.
Step 1: Who to Suspect in the ED
- Age >50 + new headache.
- Visual symptoms, especially transient monocular blindness.
- Jaw claudication = most specific symptom.
- Elevated ESR/CRP supports diagnosis.
Step 2: ED Management
- Start steroids immediately if suspicion high.
- Without vision loss: prednisone 40–60 mg PO daily.
- With vision symptoms: methylprednisolone 1 g IV daily × 3 days.
- Ophthalmology & rheumatology consult.
- Admit if vision threatened; otherwise urgent outpatient follow-up.
Common Rookie Mistakes
- Dismissing as “tension headache” in elderly patient.
- Waiting for ESR/CRP before starting steroids (treatment should not be delayed if high suspicion).
- Sending home patients with visual symptoms without steroids.
- Forgetting to ask about jaw claudication or PMR history.
Rookie Pearls
- ESR/CRP are supportive, not definitive. Normal ESR does not exclude GCA.
- Jaw claudication + vision symptoms = treat immediately.
- Temporal artery biopsy is confirmatory, but treatment is urgent.
- Steroids prevent blindness in the contralateral eye.
Take-Home Message
Temporal arteritis is a can’t-miss diagnosis in older adults. For rookies:
- Always think of GCA in patients >50 with new headache, scalp tenderness, or visual changes.
- Order ESR/CRP, but don’t wait for results to start treatment if suspicion is high.
- Give steroids early, consult ophthalmology/rheumatology, arrange biopsy later.
Remember: In temporal arteritis, ESR matters — but vision matters more. Treat first, confirm later.
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