What are the causes and treatment options for temporal headaches in patients, particularly those over 50 years old?

Temporal Headache Causes and Management

Critical Red Flag: Giant Cell Arteritis (GCA) in Patients Over 50

In any patient over 50 years old presenting with new-onset temporal headache, Giant Cell Arteritis must be immediately excluded before considering benign causes, as this represents a medical emergency requiring same-day corticosteroid initiation to prevent irreversible bilateral blindness. 1

Immediate GCA Assessment Required

• Temporal headache with jaw claudication is pathognomonic for GCA and mandates immediate high-dose corticosteroids (prednisone 40-60 mg daily) even before laboratory confirmation 1
• Jaw claudication has a positive likelihood ratio of 4.90 for GCA and is present in approximately 50% of cases 1
• Any visual symptoms (blurred vision, transient vision loss, double vision) in combination with temporal headache in elderly patients requires immediate GCA workup 1
• Scalp tenderness beyond the temporal area, temporal artery thickening, or decreased temporal artery pulse on palpation are key physical findings 1

Diagnostic Approach for Suspected GCA

• Draw ESR and CRP immediately, but never delay corticosteroids while awaiting results 1
• ESR >50 mm/h has 78.9% sensitivity, but approximately 11% of GCA patients have normal inflammatory markers, so clinical suspicion overrides laboratory values 1
• Temporal artery biopsy remains the gold standard and can be performed up to 2 weeks after starting corticosteroids without affecting diagnostic yield 1
• Same-day or next-day rheumatology consultation is recommended for fast-track evaluation 1

Common Pitfall to Avoid

Never attribute new-onset temporal headache in elderly patients to migraine or tension-type headache without first excluding GCA 2, 1. This is the most dangerous diagnostic error, as delaying corticosteroids is the strongest risk factor for permanent blindness 1.

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Primary Headache Causes (After Excluding GCA)

Migraine

Once GCA is excluded, migraine is a common cause of temporal headache in adults:

• Migraine affects ~15% of the general population and is characterized by recurrent attacks of unilateral or bilateral headache lasting 4-72 hours 2
• Temporal location is common, though migraine can affect any head region 2
• Associated symptoms include nausea, photophobia, phonophobia, and sometimes aura 2
• In older adults with migraine persisting from earlier life, clinical management often remains unchanged, though comorbidities must be considered 2

Acute migraine treatment algorithm:

1. First-line: NSAIDs (ibuprofen, diclofenac potassium, or aspirin) plus antiemetic if necessary 2
2. Second-line: Triptans if NSAIDs fail after three consecutive attacks 2
3. Third-line: Gepants (ubrogepant, rimegepant) or ditans (lasmiditan) if all triptans fail 2

Preventive therapy indications:

• Consider when patients remain adversely affected on ≥2 days per month despite optimized acute therapy 2
• First-line preventive options: angiotensin-receptor blockers (candesartan), beta-blockers (propranolol), topiramate, or magnesium 2
• Second-line: amitriptyline or flunarizine 2
• Third-line: CGRP monoclonal antibodies (galcanezumab, fremanezumab, eptinezumab) 2

Tension-Type Headache (TTH)

TTH is the most common primary headache disorder with 26% global prevalence 2:

• Typically bilateral, pressing/tightening quality, mild to moderate intensity 2
• Not aggravated by routine physical activity 2
• Lacks the prominent associated symptoms of migraine 2

Acute TTH treatment:

• Ibuprofen 400 mg or acetaminophen 1000 mg (note: lower acetaminophen doses are ineffective) 2, 3

Preventive TTH treatment:

• Amitriptyline 50-100 mg daily for chronic TTH significantly reduces monthly headache days 2, 3
• In elderly patients, start with lower doses (10 mg three times daily plus 20 mg at bedtime) due to anticholinergic risks 3
• OnabotulinumtoxinA is NOT recommended for chronic TTH (showed no benefit in 12 RCTs) 2, 3

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Other Secondary Causes in Elderly Patients

After excluding GCA, consider these additional secondary causes more common in older adults:

Structural/Vascular Causes

• Subdural hematoma: Especially with history of head trauma, progressive headache, or anticoagulation use 4
• Intracranial mass lesions: Progressive headache, headache aggravated by Valsalva maneuver, or awakening from sleep 2
• Stroke/TIA: Atypical aura symptoms, sudden onset, focal neurological deficits 2

Neurological Causes

• Trigeminal neuralgia: Sharp, electric shock-like pain in trigeminal distribution, can rarely coexist with temporal arteritis 5
• Herpes zoster: Unilateral dermatomal distribution with vesicular rash 4

When to Obtain Neuroimaging

• Unexplained abnormal findings on neurologic examination 2
• Headache worsened by Valsalva maneuver, awakens patient from sleep, newly onset in older person, or progressively worsening 2
• Atypical features not meeting strict migraine criteria 2

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Critical Clinical Algorithm for Temporal Headache in Patients Over 50

1. First action: Assess for GCA red flags (jaw claudication, visual symptoms, scalp tenderness, temporal artery abnormalities) 1
2. If ANY GCA features present: Initiate prednisone 40-60 mg immediately, draw ESR/CRP, arrange same-day rheumatology consultation 1
3. If GCA excluded: Obtain detailed headache history including quality, duration, associated symptoms, triggers 2
4. Perform neurological examination: Look for focal deficits, papilledema, meningismus 2
5. Consider neuroimaging if any red flags present (thunderclap onset, progressive course, abnormal exam, atypical features) 2
6. Classify as primary headache (migraine vs. TTH) only after excluding secondary causes 3
7. Initiate appropriate acute and preventive therapy based on headache type 2