Headache – 2 (Temporal arteritis)

Question

70-year-old gentleman with a background of osteoarthritis, hypertension, and previous ischaemic heart disease comes in with complaints of a unilateral headache since two days. He’s never known to have headaches in the past. How would you assess this patient?

Answer

I would start by taking a focused history regarding the headache, specifically looking at the onset of symptoms and whether the headache is progressive or not. I would look for red flag features in the headache and ask for any focal neurological symptoms as well. Given his age, I would ask about scalp tenderness at the temples, any unilateral visual disturbance, jaw claudication, or other constitutional symptoms. I would also inquire about systemic symptoms. After this, I would do a focused A to E assessment.

• Airway: I would ensure the airway is patent and, if necessary, insert an airway adjunct such as OP or NP airway. If the patient is tolerating an airway adjunct, I would be really worried and seek the help of the critical care team after my assessment if there was a problem with the airway assessment.
• Breathing: I would look at the observations specifically the oxygen saturation and the respiratory rate. If the patient is hypoxic or if the patient has an increased work of breathing, I’ll start the patient on supplemental oxygen therapy. I would also get a PEFR and an ABG done for this patient to see what the pH, PO2, PCO2, HCO3, and lactate are. I would be very concerned if the HCO3 and pH are very low. I would also keep an eye out on the electrolytes on the blood gas that was done. I would also arrange a portable CXR for the patient.
• Circulation: I would look at the observations specifically the BP, heart rate, and CRT. If there is evidence of hypotension or tachycardia, I would give a fluid challenge to the patient to see if there is an adequate response. If the patient remains hypotensive despite the first fluid challenge, I will give another fluid challenge and ensure the critical care team is aware of the patient. I would also ensure the patient has a working cannula and send basic bloods including septic screening. I would also request an ECG for the patient.
• Disability: I would check the patient’s blood glucose and capillary ketones, temperature, and do a focused neurological assessment that includes GCS. Specifically, if the GCS is less than 8 or if there are focal neurological deficits, I would be concerned and investigate this further. I would examine for superior temporal artery pulsations and examine the vision as well by checking visual acuity, visual fields, pupillary response, and fundus exam.
• Exposure: I would examine the patient’s abdomen and look for evidence of intra-abdominal pathology.

Question

The patient gives a history that the headaches are associated with jaw claudication, and he is exquisitely tender when you palpate his left superior temporal artery. You’re unable to feel appreciation at the left STA as well. His blood tests are still awaited. What would you do next?

Answer

This history and examination findings are consistent with a possible diagnosis of temporal arteritis. This is a rheumatology emergency, and I would start the patient on oral steroids immediately and admit the patient. I would also refer the patient to the rheumatology team to consider temporal artery biopsy or ultrasound of the temporal arteries.

The biggest worry would be visual loss, and this will need to be closely monitored. I would ensure that I escalate this to my seniors so that they would be able to review the patient.