What is the diagnosis and treatment for a 30-year-old female with severe headaches in the right frontal area that worsen when laying down and improve with prednisone (corticosteroid), and also has joint pain?

Diagnosis: Giant Cell Arteritis (Temporal Arteritis)

This clinical presentation is highly suspicious for giant cell arteritis (GCA), a medical emergency requiring immediate corticosteroid therapy to prevent permanent vision loss. The combination of severe frontal headache worsening when lying down (suggesting increased intracranial pressure from inflammation), dramatic improvement with prednisone, and concurrent joint pain in a 30-year-old female creates a compelling picture of GCA, though this is younger than the typical age of onset.1

Critical Red Flags Requiring Urgent Action

The American Society of Clinical Oncology guidelines specifically warn that patients with inflammatory arthritis and headache should be urgently evaluated for giant cell arteritis, checking for:1

• Temporal headache (present in your patient as right frontal pain)
• Visual disturbances (must be assessed immediately)
• Jaw claudication (should be specifically asked about)
• Headache that worsens with position changes (present - worse when lying down)

Permanent visual loss can occur within days of symptom onset, making this a true medical emergency requiring same-day ophthalmology referral and temporal artery biopsy consideration.1

Immediate Diagnostic Workup

Essential Laboratory Tests

• ESR and CRP - inflammatory markers will be markedly elevated in GCA1
• Complete rheumatologic panel including ANA, RF, and anti-CCP to evaluate for other inflammatory conditions1
• Complete blood count to assess for anemia of chronic disease2

Imaging Studies

• Temporal artery ultrasound or MRI if available, though biopsy remains gold standard1
• Brain imaging (MRI preferred) to exclude other causes of positional headache such as intracranial hypertension or mass lesions3

Urgent Specialist Referrals

• Immediate ophthalmology consultation to assess for visual compromise1
• Rheumatology referral for temporal artery biopsy and long-term management1

Treatment Algorithm

Immediate Treatment (Do Not Delay for Biopsy Results)

Start prednisone 40-60 mg daily (or 1 mg/kg/day) immediately if GCA is suspected, as the dramatic response to corticosteroids in your patient strongly supports this diagnosis.1 The American Society of Clinical Oncology guidelines recommend initiating corticosteroids urgently when GCA is suspected, even before biopsy confirmation, because:1

• Visual loss is often irreversible once it occurs
• Corticosteroids do not significantly affect biopsy results if performed within 1-2 weeks
• The risk of untreated GCA far outweighs steroid side effects

If Severe or Visual Symptoms Present

For patients with visual disturbances or severe disease, escalate to:1

• Methylprednisolone 1-2 mg/kg IV or higher dose pulse therapy
• Hospital admission for close monitoring

Steroid Tapering Protocol

Once symptoms improve (typically within days):1

• Continue high-dose prednisone for 2-4 weeks
• Begin slow taper by 10 mg every 2 weeks until reaching 20 mg daily
• Then taper by 2.5 mg every 2-4 weeks
• Monitor ESR/CRP every 4-6 weeks during taper1

If unable to taper below 10 mg daily after 3 months, consider steroid-sparing agents such as methotrexate or tocilizumab (IL-6 antagonist).1

Alternative Diagnoses to Consider

If GCA is Ruled Out

The positional nature of the headache (worse lying down) also suggests:

Idiopathic Intracranial Hypertension (IIH):

• More common in young women
• Headache worse with recumbency
• Requires fundoscopic exam and lumbar puncture for diagnosis3

Inflammatory Arthritis with Secondary Headache:

• The joint pain component suggests systemic inflammatory disease1, 2
• Could represent rheumatoid arthritis, lupus, or other connective tissue disease
• Would still respond to corticosteroids but requires different long-term management1

Critical Pitfalls to Avoid

1. Do not delay corticosteroid treatment while waiting for biopsy or specialist consultation if GCA is suspected - vision loss can occur rapidly1

2. Do not assume the patient is "too young" for GCA - while uncommon under age 50, it can occur and the consequences of missing it are catastrophic1, 3

3. Do not treat as simple migraine - the positional component, steroid responsiveness, and joint pain make primary headache disorder unlikely1, 3

4. Do not use NSAIDs or triptans as primary therapy when inflammatory/vascular causes are suspected1, 3, 4

5. Monitor for steroid side effects including hyperglycemia, hypertension, and osteoporosis with prolonged use1

Monitoring During Treatment

Serial assessments every 4-6 weeks should include:1, 2

• ESR and CRP levels
• Visual acuity and fundoscopic examination
• Joint examination
• Blood pressure and glucose monitoring
• Assessment for steroid-related complications