Red Flag Alert: New-Onset Headache in an Older Patient

"Hello Mr. Martin, I am Dr. Flinn, it is nice to see you."

"Yes doctor, we have met before when I've brought Sue in."

"That's right. I love Sue – she is one of our great patients. I have been telling her for years she needed to get you in here to experience chiropractic."

"Well doc, I've never needed you. I've never had back pain and I seldom get sick. I would not have come now, but this hurts some and I did not want to sit in the medical office forever. You move things along quicker."

"Regardless of the reasoning, Mr. Martin, I am happy to see you. Your paperwork says you have a bad headache. Tell me about that."

The Presentation: Worsening Right-Sided Head Pain

"Doc, you can call me Ed. I woke up yesterday with pain on the right side of my head, in my temple. It was funny because it was a sore feeling, like I had hit my head there. As the day went on, it went from soreness to a real pain. I tried lying on the sofa to watch TV after lunch, but I couldn't rest my head on the arm of the sofa. It hurt too much."

So, you are saying this started in a really specific spot, but is spreading? And that spot is really tender?"

"Yep, you've got it doc."

"Do you mind if I touch the area you are talking about?

"Ouch! You found it. That is where it started and now the whole right side hurts."

"Sorry that hurt, but I had to check. Ed, you say you never get sick. Does that include headaches? You never have headaches?

"Nope. Well I've had a headache occasionally, like anyone I suppose, but I never took more than an aspirin for it. I've never been to a doctor for a headache. But this hurt all night last night and I could not lie on my right side, even with a soft pillow. Sue said you treat headaches – so pop my neck or whatever you do."

"Ed, is Sue with you?"

"Yes she drove me over."

The Examination

"Sit up on the exam table for me. Hold your arms straight out with your palms up and close your eyes. Stay that way while I hit your knees and ankles with my little hammer. OK, now hold your foot in this position, kinda neutral here, and don't let me move it in any direction. OK, let's do the other side. I am going to take your shoes and socks off. Keep holding your arms out with your eyes closed. Don't move. Now tell me which foot I am touching and what part I am touching."

"Right little toe."

"How about now?

"Top of both feet."

"And what about now?"

"Bottom of my left big toe."

"You can drop your arms now, but keep your eyes closed. Move your feet up and down together; now alternate. Now pat your hands on your lap, together; now alternate. Like we did with your feet, tell me which hand I am touching and where."

"Right thumb."

"And now?"

"Both palms."

"You can open your eyes. I'm going to hit you with my hammer again around your elbows. OK, now shake my hands really firm. Have you have any problems with your vision since this started? How about your speech?

"I can see and talk fine. What's that have to do with anything?"

"I'll explain, but I want to go get Sue so she can hear, too. Is that OK?"

"Sure."

The Diagnosis: Three Frightening Possibilities, One Correct Call

"Now that we are all together, let's have a quick discussion about what's going on."

"Sure, give it to me doc."

"Folks, a new headache for a patient of middle age or older is not typically a good thing, especially if the patient has no history of headaches and there has not been an injury. A new headache in an older patient always triggers three immediate possibilities: a stroke, an aneurysm somewhere in the head, or a condition called temporal arteritis.

"Let's begin with the first and most common possibility, a stroke. During our initial conversation and just after, I performed a stroke screening on you. It is referred to as the FAST screening.¹ You did well on the screening. Stroke victims can have facial drooping – their face sags on one side. The F in the screening stands for face. Obviously you don't have that.

"The A is for arms. I had you extend his arms and hold them in place with your eyes closed while I performed a few other tests. It is good when the patient can hold the arms in place with the eyes closed. It is bad when the patient cannot maintain the position of the arms. You held your arms in place just fine.

"The S in the screening stands for speech. We look for slurred speech, the inability to use the correct word, etc. Your speech has been normal during our visit.

"The last part of the screening, the T, stands for time because time is of the essence with a stroke. Care must me sought quickly.

"Again, you did fine. And you did well with the other tests I performed while you were holding your arms out with your eyes closed. Reflexes, strength and sensation of your extremities are fine.

"The second possibly is an aneurysm. An aneurysm is a weakness in an artery wall that can allow the artery to expand. It can be present for a long time and result in repeated headaches. You said you have no history of repeated headaches. An aneurysm can also be present for a long time without causing symptoms and then suddenly burst. There is a high probability of death in that scenario. Patients often describe the feeling of something popping or even exploding in their head. They go from that to critical condition immediately. Fortunately, we don't have either of those scenarios here.

"The third possibility is temporal arteritis – an inflammation of an artery or arteries in the head. It is common in the temporal artery, which is where the name comes from. A more accurate name is giant cell arteritis, because it can happen in many different arteries, not just the temporal.2 In this case, an inflamed temporal artery is probably causing the localized soreness in your temple."

"Well, if it is just a little inflammation, then it's nothing to worry about, right doc? If you pop my neck, will that help?"

"It isn't as simple as that. The T for time in the FAST test applies here, too. I have no way of knowing if other arteries are also involved; if it's a problem with the ophthalmic artery going to your eye(s), it can cause partial or total blindness."²

"Blindness? Really?"

"Yes Sue, it's true. Other complications can occur, but blindness is what I am most concerned about at this moment. We have to get Ed over to the emergency room immediately so they can start treatment and perform a biopsy of the artery.

"At the ER, they'll use a needle to take a small piece of the artery so they can see its cells under a microscope. The bad cells are called giant cells. A biopsy has been the only way to make the absolute diagnosis for years. Some facilities have ultrasound equipment that can help with diagnosis, but I don't know if that is available locally."

"I'm not going to the emergency room. This is crazy. A little inflammation with a headache and you're talking blindness. Craziness!"

"Ed, if he says we are going to the ER, then we are going."

"No. I am going home to take a few aspirin. If it isn't gone in a few days, I'll go then."

"Ed, you cannot risk your sight. This isn't a negotiation; this is an emergency. You are going to the ER. Sue can run you over or I'll call an ambulance. Either way, you're going. I'll call over and let them know you are coming and why."

The Outcome

Ed was admitted through the ER, given high doses of steroids, and a biopsy was scheduled and performed. Temporal arteritis was indeed the diagnosis. The doctor in charge of Ed's care told Sue he did not think chiropractors would know about temporal arteritis, but it was good this one did, because he probably saved Ed's sight.

References

1. Berglund A, et al. Identification of stroke during the emergency call: a descriptive study of callers' presentation of stroke. BMJ Open, 2015 Apr 28;5(4):e007661.
2. Patil P, et al. Giant cell arteritis: a review. Eye and Brain, 2013;5:23-33.