Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
Differentiating Giant Cell Arteritis (GCA) from other causes of headache in older adults involves recognizing specific symptoms and the urgency associated with GCA NICE CKS. GCA is a medical emergency due to the risk of sudden irreversible sight loss and other serious complications NICE CKS.
- Giant Cell Arteritis (GCA):
- Typically affects individuals from age 40 years onwards NICE CKS.
- Headache is a common symptom NICE CG150.
- Key differentiating features include new visual loss (transient or permanent), double vision, jaw claudication, and scalp tenderness NICE CKS,NICE CG150.
- Blood tests may show elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), although these can be normal in some cases NICE CKS. Normochromic normocytic anaemia and elevated platelet count are also common NICE CKS.
- If GCA is strongly suspected, immediate treatment with high-dose glucocorticoids and urgent referral to a specialist (rheumatologist) via a fast-track pathway is crucial, ideally on the same working day and within 3 working days NICE CKS. If there is new visual loss or double vision, arrange an urgent (same day) assessment by an ophthalmologist NICE CKS. Do not delay referral while waiting for blood test results if GCA is strongly suspected NICE CKS.
- Other Headache Causes and Differentiating Features:
- Tension-type headache: Often bilateral, described as pressing/tightening (non-pulsating), mild or moderate intensity, and not aggravated by routine activities NICE CG150.
- Migraine (with or without aura): Can be unilateral or bilateral, pulsating (throbbing), moderate or severe intensity, aggravated by routine activities, and may be accompanied by sensitivity to light and/or sound, nausea, and/or vomiting NICE CG150. Aura symptoms are fully reversible, develop gradually over at least 5 minutes, and last 5 to 60 minutes, including visual disturbances, sensory symptoms, or speech disturbance NICE CG150.
- Cluster headache: Unilateral pain, typically around or above the eye and along the side of the head/face NICE CG150. Pain is severe or very severe and can be sharp, boring, burning, throbbing, or tightening NICE CG150. Associated symptoms on the same side as the headache include red and/or watery eye, nasal congestion and/or runny nose, swollen eyelid, forehead and facial sweating, and constricted pupil and/or drooping eyelid NICE CG150. Restlessness or agitation is common NICE CG150.
- Subarachnoid Haemorrhage (SAH): Characterized by a 'thunderclap' headache, which is a sudden severe headache typically peaking in intensity within 1 to 5 minutes NICE NG228. Other symptoms may include neck pain or stiffness, photophobia, nausea and vomiting, new symptoms of altered brain function (e.g., reduced consciousness, seizure, focal neurological deficit), or limited/painful neck flexion NICE NG228. Urgent investigation is required NICE NG228.
- Acute Narrow-Angle Glaucoma: May present with headache along with a painful red eye, misty vision or haloes, and sometimes nausea NICE CG150. A semi-dilated pupil may be present NICE CG150.
- Medication Overuse Headache: Occurs due to the overuse of acute headache medications and is treated by withdrawing the overused medication NICE CG150.
- General Red Flags for Headache in Older Adults (requiring further investigation/referral):
- Worsening headache with fever NICE CG150.
- Sudden-onset headache reaching maximum intensity within 5 minutes NICE CG150.
- New-onset neurological deficit or cognitive dysfunction NICE CG150.
- Change in personality or impaired level of consciousness NICE CG150.
- Recent (within 3 months) head trauma NICE CG150.
- Headache triggered by cough, Valsalva manoeuvre, sneeze, or exercise NICE CG150.
- Orthostatic headache (changes with posture) NICE CG150.
- Compromised immunity (e.g., HIV, immunosuppressive drugs) NICE CG150.
- History of malignancy known to metastasise to the brain NICE CG150.
- Vomiting without other obvious cause NICE CG150.
- A substantial change in the characteristics of their headache NICE CG150.