Headache caused by giant cell arteritis

Abstract

Giant cell arteritis (GCA) is the most common primary systemic vasculitis in older adults. Patients usually are older than 50 years and have an erythrocyte sedimentation rate (Westergren) greater than 50 mm/h. Headache is a common symptom, occurring in approximately 90% of patients. However, the most serious complications of GCA, blindness and stroke, may occur in the absence of headache. Nonspecific constitutional symptoms such as weight loss, fever, and malaise may dominate the clinical presentation. Currently, corticosteroids are the mainstay of therapy for GCA. Treatment is initiated at 0.7 to 1 mg/kg mg of prednisone (or equivalent) per day as soon as the diagnosis is suspected. The medication is tapered based on laboratory parameters and symptoms. Relapse is common, especially during the first year of therapy. Side effects from steroids in the elderly are common and often serious. Steroid resistance (manifesting as continued high dose requirements after 3 to 6 months) may complicate therapy and place patients at increased risk of side effects. Methotrexate and azathioprine have been used as steroid-sparing agents based on anecdotal evidence. More recently, evidence is emerging that antitumor necrosis factor-alpha agents may be efficacious and act as steroid-sparing agents. New-onset headache or worsening headache in a patient older than 50 years should raise the possibility of GCA and appropriate therapeutic and diagnostic measures should be begun promptly.

Giant Cell Arteritis as a Cause of First-Ever Stroke

“…All our patients were >50 years and 5 of the 6 were men, which is typical of this type of vasculitis [2, 3, 9]. The most common symptom of GCA is headache [2, 3, 7, 9, 10, 13], which was seen in all of our patients. The ESR was increased to >50 mm/h in only 3 patients, being within the normal range in the cases.…”

“…The most typical manifestation is headache [2, 3, 10, 13]. GCA is a rare cause of stroke (3–7%), most often in the vertebrobasilar territory [14, 15].…”

Tension-Type Headache Mimics

“…Giant cell arteritis (GCA) is the most common primary systemic vasculitis in older adults [6]. Headache is the most common manifestation of GCA, eventually occurring in 90% of patients [6].…”

“…Headache is the most common manifestation of GCA, eventually occurring in 90% of patients [6]. Although the pain is often more severe than most TTH attacks, the headache may be of any character, location, severity, or frequency [7] and can mimic common primary headache disorders, including TTH.…”

Resident and Fellow Section

“…Once the diagnosis is suspected, steroids should be started immediately and a biopsy obtained within a week. 1 The risk of blindness and/or stroke, the latter often in the posterior circulation, is real, and prior to the advent of steroids occurred in upwards of 50% of cases in some series. In this patient, the ultrasound imaging of his arteries did not assist in diagnosis or selection of a site for biopsy, and bilateral biopsies consequently were done.…”