What is the diagnosis and treatment for an elderly female with scalp tenderness and a full head headache?

Giant Cell Arteritis Until Proven Otherwise

In an elderly female presenting with scalp tenderness and full head headache, you must immediately check ESR and CRP and strongly consider temporal artery biopsy for giant cell arteritis (GCA), as this represents a medical emergency requiring urgent high-dose corticosteroid therapy to prevent irreversible vision loss. 1, 2

Immediate Diagnostic Workup

Check these labs immediately:

• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) should be obtained stat 1, 2
• Blood pressure measurement to assess for hypertension 2
• Serum glucose and hemoglobin A1c if vasculopathic risk factors present 1

Critical clinical features to assess:

• Jaw claudication (pain with chewing) - highly specific for GCA 1
• Visual symptoms or vision loss - present in 32-37% of GCA cases with scalp involvement 3
• Temporal artery tenderness or decreased pulse 1
• Constitutional symptoms (fever, weight loss, malaise) 4

Why This Matters: The Stakes Are High

GCA with scalp involvement carries significantly worse outcomes than typical GCA:

• Vision loss occurs in 32% of patients with scalp necrosis versus only 20% in GCA without scalp involvement 3
• Mortality is substantially elevated (standard mortality ratio 4.2) compared to GCA without scalp necrosis 3
• Diagnosis is typically delayed by approximately 1 month when scalp symptoms are present 3

The headache pattern in GCA is deceptive:

• Only 25% (6 of 24) of biopsy-proven GCA patients have headache isolated to the temples 5
• 29% have no temporal involvement at all 5
• Full head or generalized headaches occur in GCA 5
• Any new headache in an elderly patient warrants consideration of GCA, regardless of location 5, 4

Treatment Algorithm

If ESR/CRP elevated or high clinical suspicion:

1. Start high-dose corticosteroids immediately - do not wait for biopsy results 2
2. Arrange urgent temporal artery biopsy (can be performed up to 2 weeks after starting steroids without affecting diagnostic yield) 1
3. Consult neuro-ophthalmology or rheumatology to facilitate biopsy and coordinate care 1

If ESR/CRP normal but clinical suspicion remains:

• ESR can be normal in up to 10% of GCA cases (one case report showed ESR of only 21 mm/hr with confirmed GCA and scalp necrosis) 3
• Proceed with temporal artery biopsy if clinical features strongly suggest GCA 1

Alternative Diagnoses to Consider After Ruling Out GCA

Once GCA is excluded, consider these primary headache disorders:

• Tension-type headache (most common primary headache in elderly, accounting for majority of cases) 6, 7
• Migraine (less common in elderly but still occurs, often with atypical presentation) 7, 4
• Hypnic headache (specific to elderly population, awakens from sleep) 7, 4
• Medication overuse headache (relatively common in elderly) 7

Secondary causes requiring neuroimaging:

• Subdural hematoma 4
• CNS tumor 4
• Stroke 4
• CNS infection 4

Obtain MRI brain with and without contrast if:

• No improvement with initial management 1
• Any focal neurological signs 1, 2
• Progressive worsening of headache 2
• Headache awakening patient from sleep 2
• Headache worsened by Valsalva maneuver 2

Critical Pitfall to Avoid

Never dismiss scalp tenderness with headache in an elderly patient as benign tension-type headache without first excluding GCA. The consequences of missing this diagnosis include permanent blindness and increased mortality 3. While benign causes like tension-type headache are statistically more common (89.4% of elderly headache patients have primary headaches) 6, the catastrophic outcomes of untreated GCA mandate aggressive evaluation when scalp tenderness is present 1, 3.