What is the possible diagnosis for an elderly patient presenting with headache and blurring of vision?

Giant Cell Arteritis (GCA) Must Be Ruled Out Immediately

In an elderly patient presenting with headache and blurred vision, Giant Cell Arteritis is the most critical diagnosis to consider and requires immediate high-dose corticosteroid therapy before any diagnostic testing to prevent permanent bilateral blindness. 1, 2

Immediate Clinical Assessment

Critical Red Flag Symptoms to Elicit

• Jaw claudication (pain with chewing) has a positive likelihood ratio of 4.90 for GCA and is present in approximately 50% of cases 1, 2
• Scalp tenderness has a sensitivity of 38.9% and specificity of 78.9% with a positive likelihood ratio of 1.85 1
• Temporal artery abnormalities including tenderness, thickening, or decreased pulse on palpation—temporal artery thickening has 90.6% specificity with a positive likelihood ratio of 4.70 2
• Visual symptoms including transient vision loss (positive LR 1.51), double vision (positive LR 1.72), or permanent vision loss (positive LR 1.48) 1
• Constitutional symptoms including malaise, fever, weight loss, or polymyalgia rheumatica 1

Age-Specific Risk Assessment

• Age >60 years has a positive likelihood ratio of 1.25 for GCA 1
• Age >70 years has a positive likelihood ratio of 1.64 for GCA 1
• Any patient over 50 years with new-onset headache and visual symptoms warrants immediate GCA evaluation 1, 2

Immediate Management Algorithm

Step 1: Draw Labs But Do Not Wait for Results

• Obtain immediate ESR and CRP before any other testing 1, 2
• ESR >50 mm/h has 78.9% sensitivity for GCA 2
• ESR >60 mm/h is particularly informative with elevated positive likelihood ratio 1
• ESR >100 mm/h has a positive likelihood ratio of 3.11 2
• However, approximately 11% of GCA patients have normal inflammatory markers, so clinical suspicion overrides laboratory values 2

Step 2: Initiate High-Dose Corticosteroids Immediately

• Start prednisone 40-60 mg/day immediately if GCA is suspected based on clinical presentation, even before laboratory results return 2
• Do not delay corticosteroids while awaiting ESR/CRP results or temporal artery biopsy in suspected GCA with vision symptoms 2
• This represents the single most important intervention to prevent permanent bilateral blindness 2

Step 3: Arrange Temporal Artery Biopsy

• Temporal artery biopsy can be performed up to 2 weeks after starting corticosteroids without affecting diagnostic yield 2
• Biopsy has sensitivity of 67-97% and is the gold standard for diagnosis 2
• Never delay treatment to obtain biopsy first 2

Alternative Diagnoses to Consider After GCA is Excluded

Retinal or Ophthalmic Artery Occlusion

• Central retinal artery occlusion (CRAO) or ophthalmic artery occlusion (OAO) can present with sudden vision loss and headache 1
• These represent ocular "strokes" and require immediate referral to nearest stroke center 1
• Stroke risk associated with newly diagnosed OAO, CRAO, or BRAO may be as high as 25% 1
• Patients over 50 years should undergo workup for embolic sources including carotid disease and cardiac sources 1

Transient Ischemic Attack (TIA)

• Headache occurs in 26-36% of TIAs 3
• The 90-day risk of stroke after a TIA is approximately 10%, with half of strokes occurring within the first two days 4
• Blurred vision can represent transient retinal ischemia (amaurosis fugax) 5
• Patients with suspected TIA should be sent to emergency department immediately 4

Common Causes of Visual Impairment in Elderly

• Refractive errors affect 6.7 million adults older than 65 years 1
• Cataracts affect approximately 50% of adults 75 years or older 1
• Age-related macular degeneration affects 6.5% of adults 40 years or older and 13.4% of those 60 years or older 1
• However, these conditions typically do not present acutely with headache 1

Critical Pitfalls to Avoid

• Never attribute new-onset headache with visual symptoms to migraine in elderly patients, especially those over age 50 2
• Do not pursue neuroimaging first when GCA is suspected based on classic symptoms—this wastes precious time 2
• Do not delay treatment for laboratory results or biopsy when clinical suspicion is high 2
• Do not assume normal ESR/CRP excludes GCA—11% of patients have normal inflammatory markers 2
• Do not overlook jaw claudication, which is highly specific for GCA and must be specifically asked about 2