Left Temporal Pain: Causes and Management
Immediate Priority: Rule Out Giant Cell Arteritis (Temporal Arteritis)
Left temporal pain in patients over 50 years old requires urgent evaluation for giant cell arteritis (GCA), as this condition can cause irreversible blindness within days if untreated. 1, 2, 3
Critical Red Flags Requiring Same-Day Evaluation
- Age >50 years with new-onset temporal headache 1, 2
- Jaw claudication (pain with chewing that improves with rest) - the most reliable clinical symptom for GCA 3
- Visual symptoms including transient vision loss, diplopia, blurry vision, or photophobia 1, 2, 4
- Scalp tenderness over the temporal artery 1, 3
- Systemic symptoms including malaise, depression, fever, weight loss, or polymyalgia rheumatica 1, 2
Diagnostic Workup for Suspected GCA
Order erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) immediately, but do NOT wait for results to initiate treatment if clinical suspicion is high. 1, 3
- Bedside temporal artery ultrasound can provide rapid diagnosis showing characteristic "halo sign" (hypoechoic wall thickening) and is available in many emergency departments 4
- Temporal artery biopsy remains the gold standard for confirmation, though treatment should begin before biopsy if clinical suspicion is high 1, 3
- Note: Normal ESR does not exclude GCA - cases have been documented with normal inflammatory markers 4
Treatment for GCA
Start high-dose oral prednisone (40-60 mg daily) or IV prednisolone immediately if GCA is suspected, even before biopsy confirmation. 1, 2
- 20-60% of untreated or inadequately treated patients will lose vision, which may occur suddenly without warning 2
- Treatment typically continues for 23+ months with gradual tapering 3
- Biopsy can still be diagnostic up to 2 weeks after starting steroids 1
Alternative Diagnoses for Left Temporal Pain
Migraine Headache
For patients under 50 without red flags, migraine is the most common cause of unilateral temporal pain. 1, 2
- Acute treatment: Sumatriptan 50-100 mg orally (may repeat once after 2 hours if partial response; maximum 200 mg/24 hours) 5
- Contraindications to triptans: History of coronary artery disease, stroke, uncontrolled hypertension, peripheral vascular disease, or recent use of ergotamines or MAO inhibitors 5
- Common adverse effects: Paresthesia, chest/throat/neck tightness, warm/cold sensations 5
Temporomandibular Joint (TMJ) Disorder
- Pain worsens with jaw movement, chewing, or speaking 1
- Associated with jaw clicking, limited mouth opening, or malocclusion 1
- Differentiate from GCA by age (<50 years), absence of systemic symptoms, and normal inflammatory markers 1, 3
Trigeminal Neuralgia
- Sharp, electric shock-like pain in trigeminal nerve distribution 1
- Triggered by light touch, chewing, or talking 1
- Pain episodes last seconds to minutes rather than continuous 1
Tension-Type Headache
- Bilateral pressure or tightness (though can be unilateral) 1
- No associated visual symptoms or jaw claudication 1
- Responds to NSAIDs or acetaminophen 1
Critical Pitfalls to Avoid
Never dismiss temporal pain in patients >50 as "just a headache" without evaluating for GCA - the window to prevent blindness is narrow 2, 3
Do not wait for ESR/CRP results or biopsy to start steroids if clinical suspicion for GCA is high - vision loss can occur while awaiting test results 1, 4
Do not confuse GCA with migraine - while both can cause temporal pain, GCA presents with jaw claudication, scalp tenderness, and systemic symptoms that are absent in migraine 1, 2
Recognize that temporal artery biopsy can be negative in up to 10-15% of GCA cases - clinical judgment and response to steroids guide diagnosis when biopsy is negative 1