Temporal Headache: If Not GCA, What Then? Jennifer Krech, O.D Kristin Simoncelli, O.D Charles Haskes, O.D, F.A.A.O, M.S VA Connecticut, 950 Campbell Ave, West Haven, CT Abstract A symptom like temporal headache is an ominous complaint typically warranting a GCA work- up, but if negative, what else needs to be considered? This poster discusses a case exploring the differentials of temporal headaches. I. Case History a. 85-year-old white male with a chief complaint of: • Temporal head pain on mainly his right side that is tender to touch and keeps him from sleep o Onset 1 month prior and lasts about 3 hours on average o Occurs approximately 4 times per week with 7/10 pain o Had similar symptoms on and off for about 1 ½ years b. Ocular History • Normal tension glaucoma suspect, combined cataracts, dry eyes OU c. Medical History • Polymyalgia Rheumatica (PMR) • Patient fell off ladder 1.5 months ago and had dizzy spells afterwards o Did not lose consciousness, and dizziness has since resolved • Hypertension and Hyperlipidemia • History of coronary artery bypass x2 for coronary arteriosclerosis • Mild cognitive impairment/memory loss d. Medications • Aspirin 81mg, Artificial Tears, Vitamin D3 1,000 Units and Vitamin B12 1,000 MCG, Finasteride 5mg, Lisinopril 5mg and Metoprolol succinate 25mg, Simvastatin 10mg, Tamsulosin HCl 0.4 mg II. Pertinent Findings a. Best corrected distance acuity: 20/25-3 OD, 20/25 OS b. Anterior segment • Meibomian gland dysfunction and mild ectropion OU c. Posterior segment • C/D’s: 0.7/0.65 OD, 0.7/0.7 OS, (-) nerve edema/pallor • Last IOP: 12 OU, visual field and OCT were normal d. Laboratory studies • At time of eye visit: ESR: 12, CRP: 2.18, CBC: normal o Previous ESR: 7, CRP: 21, Blood pressure 144/77 e. Imaging • CT of head normal 1 month prior to eye examination III. Differential Diagnosis a. Primary/Leading • Chronic Tension headache b. Differentials • Migraine headache/cluster headache • CNS vasculitis (secondary or primary) o Including Giant Cell Arteritis/temporal arteritis • Space occupying lesion • Vascular abnormalities such as malformation or aneurysm • Infectious processes like meningitis, encephalitis, brain abscess IV. Diagnosis and Discussion a. Typically cluster and migraine headaches have more severe pain with other associated symptoms not experienced by the patient, therefore can be ruled out b. Giant Cell Arteritis and other vasculitis • Often have additional symptoms besides temporal headache/pain. In GCA, those symptoms include diplopia, vision loss, fatigue, dizziness, fever, loss of appetite, and/or jaw claudication • Normal inflammatory markers (ESR, CRP, etc.) and lack of other symptoms minimalizes the suspicion for GCA and other vasculitis c. Space occupying lesion such as tumors and infections of the brain, and vascular abnormalities all need an MRI or additional lab work to completely rule out, but are low on the differential due to previously normal CT scan, lack of other concerning neurologic symptoms, and chronic nature of his headache d. Chronic Tension headache • Based on characteristics of typical tension headaches, this is not a perfect fit, but is most likely based on the following traits: o Pain/tightness across forehead and/or sides of head. a. Our patient claims his headaches are 7/10 pain, which is atypically severe, and predominantly on one side (also unusual) o Can also have scalp pain/tenderness o Patient reports pain is often relieved by 325mg aspirin V. Treatment, management a. Blood Testing: order ESR/CRP/CBC b. Referral to neurology • Order MRI to rule out neoplasm, vascular abnormalities, infection, etc. • TSH, B12, Folate, and RPR as a reversible cause of dementia work up c. Consult primary care doctor about referral to Rheumatology • Considering PMR history, rheumatology consult may be warranted to rule out other causes of headache such as a chronic pain or inflammatory causes o 10-20% of patients with PMR develop GCA VI. Conclusion Temporal headaches can be a worrying symptom, but with the proper knowledge base, whether the diagnosis is ocular or systemic, optometrists play a role in the diagnosis and management. When visual causes of temporal headache have been ruled out, it is critical optometrists make the appropriate referral to sub-specialties to rule out non-visual malignant causes. Bibliography 1. Kapoor, Siddharth. “Headache Attributed to Cranial or Cervical Vascular Disorders.” Current Pain and Headache Reports 17.5 (2013): 334. PMC. Web. 11 Aug. 2017. 2. Gupta, Ravi, and Manjeet Singh Bhatia. “Comparison of Clinical Characteristics of Migraine and Tension Type Headache.” Indian Journal of Psychiatry 53.2 (2011): 134– 139. PMC. Web. 12 Aug. 2017. .