headaches 3

Question 1

Mrs. Jensen is an 82-year-old woman with a 20-year history of generalized osteoarthritis and well-controlled systolic hypertension. She also had an episode of ophthalmologic herpes zoster at age 60. Today, she presents with a 3-day history of right-sided headache with accompanying right-sided jaw pain on chewing. OTC analgesics have provided little relief. She states she is eating little due to the pain on chewing but is taking liquids without difficulty. Mrs. Jensen reports, “I can hardly wash my hair, my scalp is so sore.” Physical examination reveals the following: BP=168/88 mm Hg bilateral, P=88 regular, RR=18, alert, appears uncomfortable with poorly-groomed hair on the right only, PERLA, cranial nerve function II-XII intact, remaining neurological exam WNL, carotid upstroke within normal limits without bruit, and a tender, palpable, pulseless structure in the right temple area.
Mrs. Jensen’s clinical presentation is most consistent with:

Postherpetic neuralgia.
Transient ischemic attack.
Giant cell arteritis.
Angle-closure glaucoma.

Answer 1

Giant cell arteritis

Question 2

Which of the following represents the best choice of initial test to support Mrs. Jensen’s presumptive diagnosis?

Erythrocyte sedimentation rate
Enhanced contrast brain MRI
Head CT without contrast
Arterial biopsy

Answer 2

Erythrocyte sedimentation rate (auto immune vasculitis with inflammation)

Question 3

As you develop a treatment plan for Mrs. Jensen, you consider that likely:

NSAIDs will be helpful in symptom management.
Reducing her blood pressure is important to minimize headache symptoms.
Long-term, high-dose systemic corticosteroid therapy will be needed.
Opioid use is contraindicated.

Answer 3

Long-term, high-dose systemic corticosteroid therapy will be needed.

Question 4

Which of the following is a potential serious complication of Mrs. Jensen’s presumptive diagnosis?

Hemiparesis
Arthritis
Blindness
Anterior uveitis

Answer 4

Blindness

Question 5

True or false
Giant cell arteritis most frequently occurs in individuals 50 to 85 years old and is more common in females. It’s often seen with polymyalgia rheumatica

Answer 5

true

Question 6

What labs are elevated with giant cell arteritis?

Answer 6

CRP and ESR

Question 7

The presence of a tender pulseless temporal vessel is a sigh of….

Answer 7

giant cell arteritis

Question 8

Treatment for giant cell arteritis requires long-term (6-24m) high dose corticosteroids, what medications should be considered as well?

Answer 8

Aspirin to reduce risk of stroke
PPI for GI protection
Bi-phosphinate for bone protection