What is the treatment for headache caused by temporal arteritis?

Treatment of Headache from Temporal Arteritis

High-dose oral glucocorticoids (prednisone 40-60 mg/day) should be started immediately upon clinical suspicion of temporal arteritis to prevent vision loss and treat headache symptoms. 1

Initial Treatment Approach

Temporal arteritis (giant cell arteritis) headache requires prompt treatment due to the risk of permanent vision loss and other ischemic complications. The treatment algorithm is:

1. Immediate glucocorticoid therapy:

   • Start prednisone 40-60 mg/day (or 1 mg/kg/day up to 80 mg) orally upon clinical suspicion 1, 2
   • For patients with visual symptoms, consider IV methylprednisolone 500-1000 mg/day for 3-5 days before transitioning to oral therapy 1, 2

2. Initial treatment phase:

   • Maintain high-dose glucocorticoids for 2-4 weeks until symptoms resolve and inflammatory markers normalize 1
   • Headache typically responds dramatically to glucocorticoid therapy 2

3. Adjunctive therapy:

   • Add low-dose aspirin (75-150 mg/day) for patients with critical or flow-limiting involvement of vertebral or carotid arteries 1

Tapering Protocol

After initial symptom control:

• Gradually taper prednisone to 15-20 mg/day within 2-3 months 1
• Aim for ≤10 mg/day by 6 months 1
• Target ≤5 mg/day after one year 1
• Complete tapering based on clinical response and laboratory parameters (ESR, CRP)

Management of Refractory Cases or Steroid-Sparing Options

For patients with refractory headache, frequent relapses, or those requiring steroid-sparing approaches:

• Tocilizumab (162 mg subcutaneously weekly) in combination with glucocorticoids is recommended for:

  • Patients at high risk for glucocorticoid-related adverse events
  • Refractory or relapsing disease
  • Patients with active extracranial large vessel involvement 1, 3

• Methotrexate may be considered as an alternative when tocilizumab is contraindicated 1

Monitoring and Follow-up

• Regular assessment of symptoms, particularly headache and visual changes
• Monitor inflammatory markers (ESR, CRP) to assess disease activity
• Watch for glucocorticoid-related adverse effects
• Provide bone protection therapy to prevent osteoporosis 1

Relapse Management

If headache recurs during tapering:

• Increase glucocorticoid dose by 5-15 mg/day above the last effective dose 1
• Consider adding tocilizumab (preferred) or methotrexate if not already on immunosuppressive therapy 1

Common Pitfalls to Avoid

1. Delaying treatment while awaiting biopsy results - This can lead to irreversible vision loss; treatment should begin immediately upon clinical suspicion 1

2. Tapering steroids too quickly - This is a common cause of relapse and recurrent headache 1

3. Inadequate initial dosing - Starting with doses below 40 mg/day may be insufficient to control disease activity and prevent complications 2, 1

4. Failing to provide prophylaxis against steroid-related complications - Bone protection therapy is essential 1

5. Assuming a negative temporal artery biopsy rules out GCA - False negatives can occur; clinical judgment should guide treatment decisions 1

The dramatic response of headache to glucocorticoid therapy is often a key diagnostic feature of temporal arteritis, and prompt treatment is essential to prevent potentially devastating complications such as permanent vision loss.