Temporal Arteritis presenting with Headache and Jaw Pain

75 yo AAF, NH resident started to c/o occasional jaw pain 4 months ago. She also began to c/o headache 3 weeks ago, throbbing, 5/10, worse in the afternoon, radiating down the neck.

Problem list: CVA with R hemiparesis, Depression, AFib, OA, Gout, PPD (+), DM2

Medications: ASA, Clonidine, Colace, Lasix, Glyburide, Lisinopril, Metoprolol, MVT, Nifedipine, MVT, Ambien, Elavil

Physical exam:
WD/WN sitting comfortably in wheelchair
VSS
Neuro: R sided hemiparesis
The rest of the physical exam WNL.

What do you think is going on?
Tension headache
Headache due to cervical spondylosis
Headache due to TMJ dysfunction
Temporal arteritis

What is the one test that you should do?
ESR
And of course, examine the eyes.

What happened?
ESR 83
Patient was started on Prednisone 60 mg PO QAM.
She felt better and her pain decreased to 3/10.

What happened next?
You probably remember that the patient has DM. Her HbA1c was 10, one year ago, and was controlled to a level of 7, six months later.

After starting the steroids, 3 weeks ago, patient's BS has been consistently above 200 despite increasing her Glyburide dose to 5 mg PO BID.

What to do to control her BS?
We have 2 options:
-To decrease Prednisone dose
-To increase Glyburide dose

Usually, temporal arteritis treatment continues for at least 4-6 weeks and the response is monitored by symptoms and ESR.

What happened next?
ESR was ordered.
Glyburide dose was increased to 7.5 mg PO QAM, 5 mg PO QPM.

Final diagnosis: Temporal arteritis. Hyperglycemia as a side effect to steroid treatment in DM patient.

What did we learn from this case?
Suspect temporal arteritis in elderly patients with headache and/or jaw pain.
ESR is a very sensitive test for temporal arteritis.

When treating patients with steroids, monitor for increased BS and BP, and mood changes (the mnemonic is BBP, i.e. BS, BP, Psych)

Resources:
Polymyalgia Rheumatica and Temporal Arteritis - AFP 08/00