AKT · Neurology/Headache & facial pain

Giant cell arteritis (temporal arteritis)

Large/medium-vessel granulomatous vasculitis of the cranial arteries

Overview

A granulomatous vasculitis of medium/large arteries (especially the branches of the external carotid) in the OVER-50s. A sight-threatening emergency: new headache, scalp tenderness and jaw claudication with a very high ESR. Treat with high-dose steroids IMMEDIATELY — before the biopsy — to prevent irreversible blindness.

Recognise

New unilateral temporal headache with scalp tenderness (painful to comb hair) and a thickened/non-pulsatile/tender temporal artery
JAW CLAUDICATION (ache on chewing) — the most specific symptom; visual symptoms (amaurosis fugax, diplopia, sudden painless visual loss from anterior ischaemic optic neuropathy)
Associated with polymyalgia rheumatica (proximal girdle pain/stiffness) in ~40–50%; age >50, raised ESR/CRP

Red flags

Any visual symptom (transient or established) = ophthalmic emergency — irreversible blindness can follow within hours/days; treat first, investigate after

Differentials & how to tell them apart

Tension/migraine headacheyounger, normal ESR, no jaw claudication or visual loss

Trigeminal neuralgiabrief electric-shock facial pains, not a constant temporal headache with raised ESR

Other anterior ischaemic optic neuropathy (non-arteritic)normal ESR/CRP, no systemic GCA features

Takayasu arteritislarge-vessel vasculitis in younger patients

Investigations

Markedly raised ESR (often >50) and CRP; TEMPORAL ARTERY BIOPSY (skip lesions — a negative biopsy does not exclude it) and/or temporal artery ultrasound (halo sign). Do NOT delay steroids for the biopsy.

Management

High-dose prednisolone immediately (IV methylprednisolone if visual loss) — before biopsy

1Start high-dose prednisolone IMMEDIATELY on clinical suspicion; if there is visual loss/amaurosis give IV methylprednisolone. Arrange temporal artery biopsy/ultrasound and urgent ophthalmology if any visual symptom — but do NOT delay steroids for the test.Gate: Treat BEFORE the biopsy — steroids must not wait for confirmation because blindness is irreversible and can occur within hours; a negative biopsy (skip lesions) does not exclude GCA if the clinical picture fits
2Add low-dose aspirin and gastric/bone protection; slow steroid taper over 12–24 months guided by symptoms/ESR; tocilizumab for relapsing disease; manage coexisting polymyalgia rheumatica.

High-dose oral prednisolone (e.g. 40–60 mg) — start IMMEDIATELY on clinical suspicion — do not wait for the biopsy

IV methylprednisolone — if there is visual loss or amaurosis

Low-dose aspirin + PPI; bone/GI protection — adjuncts; long steroid course needs bone protection

Tocilizumab — steroid-sparing in relapsing/refractory disease (specialist)

Key points

Age >50 + new temporal headache + jaw claudication + raised ESR = GCA → steroids NOW. Jaw claudication and visual loss are the high-yield features. Associated with polymyalgia rheumatica. (Also a rheumatology/ophthalmology topic.)

Monitor & prognosis

Symptoms, ESR/CRP, visual status, steroid side effects (glucose, bone, BP).

Excellent for the headache; vision lost before treatment rarely recovers — hence the urgency.

Source: NICE CKS Giant cell arteritis; BSR guideline