What is the assessment and treatment for an elderly female with a 4-day history of headache, left temple pain, and left eye pain?

Urgent Assessment for Giant Cell Arteritis Required

This elderly female with 4 days of unilateral temple and eye pain requires immediate ESR and CRP testing with same-day initiation of high-dose corticosteroids if giant cell arteritis (GCA) is suspected, as any delay risks permanent, irreversible vision loss. 1, 2

Immediate Red Flag Assessment

This presentation demands urgent evaluation for GCA because:

• Temporal headache with eye pain in an elderly patient are pathognomonic symptoms for GCA, which represents a medical emergency 1
• The unilateral temple location with ipsilateral eye pain in an elderly female creates high clinical suspicion for arteritic involvement 1, 2
• Vision loss from GCA is irreversible once it occurs, and the contralateral eye can become involved within days if untreated 1

Critical Clinical Questions to Ask Immediately

Ask specifically about these highly specific GCA features:

• Jaw claudication (pain with chewing) - this is pathognomonic for GCA and has 90.6% specificity 1, 2
• Any vision changes, even transient blurring or dimming 1
• Scalp tenderness when combing hair or lying on a pillow 2
• Constitutional symptoms: fever, weight loss, malaise 3

Physical Examination Priorities

• Palpate temporal arteries bilaterally for tenderness, thickening, or decreased pulse - temporal artery abnormalities have 88-90% specificity 1
• Complete neurologic examination to exclude stroke or other focal deficits 4, 3
• Visual acuity and fundoscopic examination to assess for ischemic optic neuropathy 1

Immediate Laboratory Testing

• Order ESR and CRP stat - ESR >50 mm/h has 78.9% sensitivity and CRP elevation has 79.2% sensitivity for GCA 1, 2
• Critical caveat: Approximately 11% of GCA patients have normal inflammatory markers, so clinical suspicion overrides laboratory values 1

Treatment Decision Algorithm

If ANY of the following are present, initiate high-dose corticosteroids immediately without waiting for test results:

• Jaw claudication 1, 2
• Temporal artery tenderness, thickening, or decreased pulse 1, 2
• Any vision symptoms 1
• High clinical suspicion based on age + unilateral temple pain + eye pain 1, 2

Do not delay corticosteroids while awaiting ESR/CRP results or temporal artery biopsy - this is the single most critical pitfall to avoid 1

Subsequent Diagnostic Steps

• Arrange urgent temporal artery biopsy within days, which can be performed up to 2 weeks after starting steroids without affecting diagnostic yield 1, 2
• Consult neuro-ophthalmology or rheumatology to facilitate biopsy and coordinate care 1, 2

If GCA is Ruled Out: Alternative Diagnoses

Once life-threatening causes are excluded, consider:

• Acute angle-closure glaucoma - requires ophthalmology evaluation for unilateral eye pain 3
• Migraine or tension-type headache - but new-onset headache after age 50 should never be attributed to migraine without excluding GCA first 1
• Intracranial lesion - obtain MRI brain with and without contrast if progressive worsening, awakening from sleep, or worsening with Valsalva 2

Acute Treatment if Secondary Causes Excluded

For symptomatic relief while diagnostic workup proceeds:

• NSAIDs are preferred first-line: ibuprofen 400 mg or naproxen 500 mg 5
• Start with low doses due to elderly status and monitor for GI toxicity (NSAIDs implicated in 23.5% of adverse drug reaction hospitalizations in older adults) 5
• Limit acute medications to no more than 2 days per week to prevent medication-overuse headache 5
• Avoid triptans in elderly patients due to cardiovascular disease risk 6, 7

When to Obtain Neuroimaging

Order MRI brain with and without contrast if:

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

Morbidity and Mortality Priority

The absolute priority is preventing permanent bilateral blindness from untreated GCA - immediate corticosteroid therapy is the single most important intervention to preserve quality of life and represents a true medical emergency in elderly patients with this presentation 1