Headache OSCE - Temporal Arteritis | Free OSCE Practice

Case Overview

Age/Sex: 66-year-old female
Occupation: Retired school secretary
Setting: General practice / urgent clinic
Chief complaint: "I've had a bad headache"

Patient Script

Who I Am

I'm a 66-year-old retired school secretary who lives with my husband and does the shopping and cooking when I can.

What Brings Me In

I have a really bad headache on the side of my head and my scalp feels sore — it started about a week ago and it's getting worse.

My Story

About 10 days ago I noticed a dull ache over my right temple that I thought was from stress. Over the next few days it got worse and about 3 days ago it became a constant, throbbing pain on the right side of my head. The area over my temple feels very tender to touch, and my scalp is sore when I brush my hair. I also noticed that when I chew my food, especially tougher things like meat, my jaw gets tired and painful after a minute or so — that started around one week ago. Yesterday morning my right eye was a bit blurry for a few hours and now things on the right look a bit dimmer than the left. I've also felt more tired than usual and I lost about 3 kg over the past month without trying. I had a "sinus infection" last month that cleared up, and I had a dental filling put in two weeks ago, so I wondered if those were causing this.

I've been taking paracetamol and some ibuprofen which help a little for the pain. Nothing like this has happened before.

My Medical Background

Past medical history: Type 2 diabetes mellitus (diagnosed 12 years ago), hypertension, osteoarthritis (knees), hyperlipidaemia
Medications: Metformin 1 g twice daily, gliclazide 80 mg once daily, lisinopril 10 mg daily, atorvastatin 20 mg nightly, occasional ibuprofen PRN for knee pain
Allergies: No known drug allergies
Social: Lives with husband, ex-smoker (20 pack-years, quit 10 years ago), drinks alcohol occasionally (1–2 units a week)
Family: Mother had rheumatoid arthritis; father had coronary artery disease

What I Think & Worry About

I think this might be something serious in my head like a bleed or maybe a tumour.
I worry I might lose my sight — that scared me when my eye went blurry.
I expect you to find out what's causing it and do something to stop it getting worse.

If You Ask Me About Other Symptoms...

Vision: "My right eye was a bit blurry yesterday for a few hours; it's not gone completely but things on that side look dimmer now."
Scalp: "My scalp is very sore — even brushing my hair hurts."
Jaw: "My jaw aches when I chew hard food and gets "tired" after a minute or two."
Fevers/Night sweats: "I haven't had a high fever but I've felt feverish a few times and I've had night sweats now and then."
Neck stiffness/photophobia: "No neck stiffness and bright lights don't really bother me more than usual."
Recent infections/dental work: "I had a dental filling two weeks ago and a bad cold a month ago — both seemed to clear up."
Neurological symptoms: "No weakness, numbness, or difficulty speaking; I can walk fine."
Medications: "I take my diabetes pills and blood pressure medicine every day; sometimes I take ibuprofen for my knees."
Appetite/weight: "My appetite is a bit down and I've lost a few kilos over the last month."

Clinical Summary

Examination

General: alert, mildly unwell-looking, afebrile (37.5°C)
Blood pressure: 150/85 mmHg; Heart rate: 88 bpm; Respiratory rate: 16/min; SpO2: 98% on air
Head: focal tenderness over the right temporal artery region; the right temporal artery feels slightly thickened and tender to palpation
Scalp: tenderness to light touch over right temporal and parietal scalp
Jaw: pain and fatigue on prolonged jaw clenching/chewing reproduced on examination
Eyes: visual acuity right 6/18, left 6/9 (unaided); relative afferent pupillary defect on the right is possible on testing; ocular movements full; fundoscopic exam: disc margins slightly blurred on the right (suggestive of possible optic nerve head swelling) but not gross haemorrhage
Neurology: cranial nerves intact apart from above; no motor or sensory deficits; gait normal

Investigations

ESR: 95 mm/hr (markedly elevated)
CRP: 72 mg/L (elevated)
Full blood count: Hb 10.8 g/dL (mild normocytic anaemia), WBC 8.5 x10^9/L, Platelets 460 x10^9/L (thrombocytosis)
Serum glucose (random): 14.2 mmol/L (elevated; known diabetes)
Creatinine: 88 µmol/L (within usual limits for age)
Temporal artery duplex ultrasound: halo sign of the right superficial temporal artery (if performed)
ECG: sinus rhythm, no acute ischaemia
Consider urgent ophthalmology assessment (visual fields/optic coherence tomography)

Diagnosis

Primary diagnosis:

Giant cell (temporal) arteritis presenting with new-onset unilateral temporal headache, scalp tenderness, jaw claudication, elevated inflammatory markers (ESR/CRP), and evolving visual disturbance — age >50 and supportive ultrasound/blood tests consistent with GCA.

Differential diagnoses:

Tension or migraine-type headache — less likely given age of onset, localised temporal tenderness, jaw claudication and raised ESR/CRP.
Dental or temporomandibular disorder related pain — possible red herring given recent dental work, but does not explain scalp tenderness, raised inflammatory markers or visual symptoms.
Sinusitis — recent history of a cold could mislead, but physical and lab findings point away (no purulent nasal symptoms, marked systemic inflammation unexplained by simple sinusitis).
Cervical spondylosis/cervicogenic headache — may cause occipital/neck pain but not jaw claudication or raised ESR/CRP.
Intracranial mass or stroke — less likely acutely without focal neurological deficits beyond visual symptoms, but should be considered if atypical features present.

Management

Immediate: Start high-dose corticosteroid therapy without delay given visual symptoms — give IV methylprednisolone 500–1000 mg daily for 1–3 days if vision rapidly deteriorating, otherwise start high-dose oral prednisolone 40–60 mg daily (start today).
Do NOT wait for temporal artery biopsy or imaging before initiating steroids.
Urgent ophthalmology referral for assessment and close monitoring of vision.
Arrange temporal artery biopsy (ideally within 1–2 weeks while patient remains on steroids) and/or temporal artery ultrasound to support diagnosis.
Baseline investigations and monitoring: ESR/CRP, FBC, LFTs, glucose, bone profile, and blood pressure prior to steroid initiation and regularly thereafter.
Diabetes management: adjust hypoglycaemic regimen and arrange inpatient/outpatient review for closer glucose monitoring while on high-dose steroids (may require temporary insulin therapy).
Preventive measures: start calcium and vitamin D; consider bisphosphonate if prolonged steroid therapy anticipated; consider PPI for gastric protection if on NSAID or at risk.
Antiplatelet: consider low-dose aspirin (75–100 mg daily) to reduce ischaemic complications after assessing bleeding risk and current aspirin use.
Referral: urgent rheumatology follow-up for continued management and steroid tapering plan; coordinate long-term plan including steroid-sparing options if needed.
Patient education: explain the risk of permanent vision loss, need for immediate treatment, possible steroid side effects (mood change, higher blood sugar, infection risk, weight gain) and need for monitoring.

Key Learning Points

Temporal (giant cell) arteritis should be suspected in patients over 50 with new unilateral temporal headache, scalp tenderness, jaw claudication and elevated ESR/CRP — urgent treatment is required to prevent irreversible visual loss.
Do not delay high-dose corticosteroids while awaiting diagnostic tests (temporal artery biopsy or imaging); coordinate urgent ophthalmology and rheumatology input.
In patients with diabetes and other comorbidities, plan for close glucose monitoring and medication adjustments when initiating high-dose steroids.