What is the appropriate diagnosis and treatment for an elderly female presenting with scalp tenderness and headache, with suspicion of temporal arteritis?

Giant Cell Arteritis: Immediate Diagnosis and Treatment

An elderly female presenting with scalp tenderness and headache requires immediate initiation of high-dose corticosteroids for presumed giant cell arteritis (GCA) before any diagnostic testing, as this represents a medical emergency where delays can result in irreversible bilateral blindness. 1, 2

Immediate Clinical Assessment

Assess for pathognomonic features that confirm the diagnosis:

• Jaw claudication (pain with chewing) is highly specific for GCA and should be specifically asked about 3, 1, 2
• Temporal artery abnormalities including tenderness, thickening, or decreased pulse on palpation 3, 1
• Visual symptoms including transient vision loss (amaurosis fugax), diplopia, or acute vision deterioration indicating ischemic optic neuropathy 2, 4, 5
• Constitutional symptoms such as malaise, fever, or polymyalgia rheumatica 3, 5, 6

The combination of scalp tenderness and headache in an elderly patient is sufficient to warrant immediate treatment, even without other classic features. 1, 2

Immediate Management Protocol

Start high-dose corticosteroids immediately—do not wait for laboratory results or biopsy. 1, 2

• High-dose oral prednisone (typically 40-60 mg daily) or intravenous prednisolone should be initiated at the bedside 2, 4
• Treatment must begin before ESR/CRP results return and before temporal artery biopsy 1, 2
• This immediate intervention is the single most important step to prevent permanent bilateral blindness 2

Draw ESR and CRP stat, but do not delay treatment for results: 1, 2

• ESR >50 mm/h has 78.9% sensitivity for GCA 3
• CRP elevation has 79.2% sensitivity and 54.2% specificity 3
• However, approximately 11% of GCA patients have normal inflammatory markers, so clinical suspicion overrides laboratory values 3

Diagnostic Confirmation

Arrange urgent temporal artery biopsy within days of starting steroids: 1, 2

• Biopsy can be performed up to 2 weeks after initiating corticosteroids without affecting diagnostic yield 1, 2
• Temporal artery abnormalities on biopsy are the gold standard for diagnosis 5
• Negative biopsy does not exclude GCA if clinical suspicion remains high 4

Obtain neuro-ophthalmology or rheumatology consultation urgently: 1, 2

• Facilitates temporal artery biopsy arrangement 1, 2
• Coordinates ongoing corticosteroid management and monitoring 2

Critical Pitfalls to Avoid

Never delay corticosteroids while awaiting diagnostic confirmation in suspected GCA with headache and scalp tenderness. 1, 2

• Do not pursue neuroimaging first when GCA is suspected based on classic symptoms—this wastes precious time 2
• Do not attribute symptoms to migraine, tension headache, or other benign causes in patients over 50 with new-onset headache and scalp tenderness 2, 7
• Do not wait for temporal artery biopsy results before starting treatment 1, 2

The priority is preventing permanent bilateral blindness, which occurs when the contralateral eye becomes involved in untreated GCA. 2 Immediate corticosteroid therapy dramatically reduces this risk and represents the most critical intervention to preserve quality of life. 2

Additional Evaluation if Atypical Features Present

Consider MRI brain with and without contrast only if: 1

• No improvement with initial corticosteroid management 1
• Focal neurological signs develop 1
• Progressive worsening of headache despite treatment 1
• Headache awakens patient from sleep or worsens with Valsalva maneuver 1

The diagnostic accuracy of physical findings shows temporal artery thickening has 90.6% specificity with a positive likelihood ratio of 4.70, while temporal artery loss of pulse has 88.2% specificity. 3 However, the absence of these findings does not exclude GCA when scalp tenderness and headache are present in an elderly patient. 3, 1