What is the next step in managing an elderly woman with unilateral headache, jaw pain, worsening vision, and hypertension?

Immediate High-Dose Corticosteroid Therapy

This patient requires immediate initiation of methylprednisolone (or equivalent high-dose corticosteroid) for presumed giant cell arteritis (GCA) before any diagnostic testing, given the constellation of temporal headache, jaw claudication, and acute vision loss in an elderly patient.

Clinical Reasoning

This presentation is classic for GCA with impending or early vision loss, which constitutes a medical emergency:

• Temporal headache with jaw claudication in an elderly patient are pathognomonic symptoms for GCA 1, 2
• Acute vision deterioration indicates ischemic optic neuropathy from arteritic involvement, representing irreversible vision loss if untreated 1
• The 3-week duration of headache with acute worsening of vision over one day suggests progressive arterial inflammation with acute ischemic complications 1

Immediate Management Algorithm

Step 1: Start Corticosteroids Immediately

• Initiate high-dose corticosteroids before any diagnostic testing to prevent further vision loss 1, 2
• Do not delay treatment for laboratory results or biopsy 1
• The hypertension (150/90 mm Hg) is not a contraindication and does not require immediate treatment with labetalol in this context 3

Step 2: Obtain Laboratory Studies Urgently

• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) should be drawn immediately, but treatment should not await results 1, 2
• Complete blood count with platelets 1
• If the patient has diabetes, monitor glucose closely as corticosteroids will affect glycemic control 1

Step 3: Arrange Temporal Artery Biopsy

• Temporal artery biopsy should be performed if ESR/CRP support GCA diagnosis, but can be done within days after starting steroids without affecting diagnostic yield 1, 2
• Consultation with neuro-ophthalmology facilitates biopsy and ongoing management 1, 2

Why Other Options Are Incorrect

Noncontrast Head CT

• CT imaging has no role in diagnosing GCA and would only delay critical treatment 1
• While CT angiography can detect vascular abnormalities, the clinical diagnosis of GCA is based on symptoms and inflammatory markers, not imaging 4
• Neuroimaging is only indicated when secondary headache from other causes (tumor, stroke) is suspected based on red flags, which are not present here 1

Labetalol

• The blood pressure of 150/90 mm Hg does not constitute a hypertensive emergency requiring immediate IV antihypertensive therapy 5, 6, 3
• Hypertensive emergencies require acute end-organ damage (not present here) and systolic BP >180 mm Hg or diastolic BP >120 mm Hg 5, 6
• Treating the blood pressure would distract from the true emergency: impending permanent vision loss from GCA 1

Carbamazepine

• This is a treatment for trigeminal neuralgia, which presents with brief, lancinating facial pain, not the throbbing temporal headache and jaw claudication seen here 1
• Carbamazepine has no role in GCA management 1

Critical Pitfalls to Avoid

• Never delay corticosteroids while awaiting ESR/CRP results or temporal artery biopsy in suspected GCA with vision symptoms 1, 2
• Do not attribute symptoms to migraine in elderly patients with new-onset headache after age 50, especially with jaw claudication 1
• Do not pursue neuroimaging first when GCA is suspected based on classic symptoms—this wastes precious time 1
• Recognize that vision loss from GCA is often irreversible once it occurs, making immediate treatment paramount for preventing bilateral blindness 1

Morbidity and Mortality Considerations

The priority here is preventing permanent bilateral blindness, which occurs in untreated GCA when the contralateral eye becomes involved (often within days) 1. Immediate corticosteroid therapy dramatically reduces this risk and represents the single most important intervention to preserve quality of life 1, 2. The modest elevation in blood pressure poses no immediate threat compared to the vision emergency 5, 6, 3.