MosaicED Brain Teaser!
A 67 year old political youth activist comes in to see you in your GP practice with a throbbing headache that has been worse in the morning. The side of her head is tender to the touch and feels a bit warm. You ask about family history and she says "I think my mum might have had a weird condition where she got bad hip and shoulder pain, I can't remember..... I mean, I'm not losing my memory I'm juvenile, I mean a youth, I mean.... Kowabunga dude."
What is the most likely diagnosis?
- A-Benign intracranial hypertension
- B-Cluster headache
- E-Subarachnoid haemorrhage
- F-Temporal arteritis
- G-Temperomandibular joint dysfunction
- H-Tension headache
- I-Trauma causing a headache
- J-Trigeminal neuralgia
- K-Tumour causing a headache
F-Temporal arteritis. Temporal arteritis is the main manifestation of giant cell arteritis. This is a disease that is closely linked to polymyalgia rheumatica, often described as on the same spectrum, meaning it's probably the same disease manifesting in different ways. Roughly 70% of people with GCA have PMR. It will present as throbbing headache with temporal artery tenderness. It is more common in people over the age of 50. It can present with, amaurosis fugax, a curtaining loss of vision which is an emergency as they can permanently lose their vision if it spreads to the arteries that supply the eyes. Treatment with steroids is urgent. Methotrexate is the mainstay of long term treatment. Someone with GCA can have an ESR above 100. A favourite question for a consultant to ask on ward rounds is; what are the 6 conditions that can give an ESR above 100? In truth a lot of conditions can cause an ESR to go above 100 but the answer that consultant wants are GCA/PMR, Multiple myeloma/metastatic cancer, Sepsis, TB, and chronic inflammation i.e. rheumatoid arthritis and SLE.
Remember: headache with tender forehead equals immediate steroid treatment to protect eyes and ESR above 100 = GCA/PMR, MM/metastatic cancer, Sepsis, TB, or chronic inflammation (Rheumatoid and SLE).