What are the causes and treatment options for left temporal pain?

Left Temporal Pain: Causes and Management

Immediate Priority: Rule Out Giant Cell Arteritis (Temporal Arteritis)

Left temporal pain requires urgent evaluation for giant cell arteritis (GCA), a vision-threatening emergency that demands immediate high-dose corticosteroid therapy to prevent irreversible blindness. 1, 2, 3

Critical Red Flags Requiring Same-Day Action

• Scalp tenderness over the temporal artery - palpate for a swollen, tortuous, or tender temporal artery 1, 2
• Visual symptoms - including transient vision loss (amaurosis fugax), blurry vision, diplopia, or photophobia 1, 2, 3
• Jaw claudication - pain with chewing or speaking that worsens with continued use 2, 3
• Constitutional symptoms - malaise, fever, weight loss, or polymyalgia rheumatica symptoms 1, 2
• Age >60 years - GCA predominantly affects patients over 60, with higher incidence in women 1, 3

Diagnostic Workup for Suspected GCA

• Obtain erythrocyte sedimentation rate (ESR) immediately - though a normal ESR does not exclude GCA 1, 4
• Consider bedside temporal artery ultrasound - can show characteristic "halo sign" and may expedite diagnosis when biopsy is delayed 4
• Arrange temporal artery biopsy - the gold standard for diagnosis, though treatment should not be delayed waiting for biopsy 1, 3
• Start high-dose oral prednisone (40-60 mg daily) or IV prednisolone immediately if clinical suspicion is high, even before biopsy confirmation 1, 2

Critical Pitfall to Avoid

Do not wait for biopsy results to initiate corticosteroid therapy - 20-60% of untreated patients will lose vision, and blindness may occur suddenly without warning 2. Corticosteroids can be started and will not significantly affect biopsy results if performed within 1-2 weeks 1.

Alternative Diagnoses to Consider

Neurological Causes

• Migraine headache - typically unilateral temporal pain with throbbing quality, photophobia, and nausea, but lacks scalp tenderness and jaw claudication 1
• Trigeminal neuralgia - sharp, electric shock-like pain in trigeminal nerve distribution, but pain is brief (seconds) rather than sustained 1, 5
• Temporomandibular joint (TMJ) syndrome - pain worsens with jaw movement but lacks systemic symptoms and vascular findings 1

Vascular Causes

• Carotid artery occlusive disease - may present with transient visual symptoms but typically includes other neurological deficits 1
• Hypertensive headache - check blood pressure, but temporal location alone is not specific 1

Structural Causes

• Temporal encephalocele - rare cause of temporal pain, typically presents with seizures rather than isolated pain 5

Diagnostic Algorithm

1. First: Assess for GCA red flags (age >60, scalp tenderness, visual symptoms, jaw claudication, constitutional symptoms) 1, 2, 3

   • If present → Order ESR/CRP stat, start high-dose corticosteroids immediately, arrange temporal artery biopsy 1, 3
   • If absent → Proceed to step 2

2. Second: Characterize pain pattern 1

   • Throbbing with photophobia/nausea → Consider migraine
   • Brief electric shock-like pain → Consider trigeminal neuralgia
   • Pain with jaw movement only → Consider TMJ syndrome

3. Third: Perform focused physical examination 1, 2

   • Palpate temporal arteries bilaterally for tenderness, swelling, or absent pulse
   • Check visual acuity and perform fundoscopic examination
   • Assess jaw opening and TMJ tenderness
   • Measure blood pressure

4. Fourth: Order appropriate imaging if diagnosis remains unclear 4

   • Temporal artery ultrasound for suspected GCA when available
   • Brain MRI for atypical presentations or neurological deficits

Treatment Based on Diagnosis

For Confirmed or Suspected GCA

• Initiate prednisone 40-60 mg daily immediately - taper slowly over 12-24 months based on symptom response and ESR normalization 1, 2
• Monitor for treatment response - symptoms typically improve within 24-48 hours of starting corticosteroids 1
• Arrange ophthalmology follow-up - for baseline and serial visual assessments 2

For Migraine

• Acute treatment - NSAIDs, triptans, or antiemetics for active headache
• Preventive therapy - consider if headaches are frequent or disabling

For TMJ Syndrome

• Conservative management - soft diet, NSAIDs, jaw exercises, and dental referral if persistent

The most critical action is recognizing GCA early, as this is the only temporal pain etiology that causes irreversible blindness if treatment is delayed. 2, 3