TEMPORAL ARTERY EXAMINATION: PART OF THE HEADACHE EXAMINATION IN THE ELDERLY

A patient presents with jaw pain.  At triage, 100.4 is found to be her temperature.  She is a poor historian. You ask specific, targeted questions in an effort to narrow the differential diagnosis.  She answers each by redoubling her description of the pain. Routine examination is unrevealing.  The dentition appears normal.  She has difficulty localizing the pain. You palpate for pre and postauricular lymph nodes and note she has scalp tenderness.  Could this be temporal arteritis?

 

Temporal arteritis is actually a misnomer, as it tends to affect any of the cranial vessels from the aortic arch.  The pathologic diagnosis, and the modern preferred term, is “giant cell arteritis.” It is strongly associated with polymyalgia rheumatica, a periarticular synovitis presenting with pain and morning stiffness of the shoulder girdle, but can also affect the neck and pelvic girdle.(Salvarani NEJM 2002)

 

Giant cell arteritis presents with four categories of symptoms:

1) Cranial arteritis – stroke, amaurosis fugax, diplopia, etc.

2) Extracranial arteritis – headache and scalp tenderness, jaw claudication, etc.

3) Systemic symptoms – fatigue, anorexia, fever, malaise, weight loss, fever etc.

4) Polymalgia rheumatica – synovitis of the periarticular structures of the shoulder and other musculoskeletal units, especially hand edema.

 

Temporal arteritis is a pathologic diagnosis, and this pathology is actually something that can be directly examined. The temporal artery emerges preauricularly and forks into the frontal branch and parietal branch. Palpate in these areas.  Does it feel inflamed? Is there tenderness?  Dilation?  Absence of a pulse?  Any of these abnormalities might indicate temporal arteritis.

 

The 1990 American College of Rheumatology criteria for diagnosis starts with age,  headache, and any temporal artery abnormality on physical examination.(Hunter Arthritis Rheum 1990)

 

The original description by Hutchison in 1890 tells you what you might see: red linear streaks on the head, painful, swollen temporal arteries, which eventually become firm and pulseless.

 

Take home points:

-The temporal artery is accessible to palpation

-Temporal arteritis can be recognized at the bedside by inspection and palpation of the temporal artery

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