An older patient with unilateral temple tenderness and a tender temporal artery, with no focal neurological signs, is most likely diagnosed with which condition?

• A. Migraine headache
• B. Tension headache
• C. Cluster headache
• D. Temporal arteritis

Answer: (D)

This scenario tests recognizing temporal arteritis (giant cell arteritis) as an emergency inflammatory vasculitis in adults over 50. The combination of new unilateral temple/headache and a tender temporal artery points to inflammation of the temporal artery itself. This condition can rapidly progress to vision loss if not treated promptly, even before a biopsy is done.

Because of the risk to the optic nerve, treatment should begin immediately with high‑dose glucocorticoids to protect vision. Start commonly with about 40–60 mg of prednisone daily (or an equivalent dose of another steroid), and arrange urgent ophthalmology input. While steroids are started, obtain inflammatory markers (ESR and CRP) and schedule a temporal artery biopsy to confirm the diagnosis later, since the biopsy is the definitive test but should not delay treatment. If there are any signs of visual disturbance, consider higher or intravenous steroid therapy and expedited eye evaluation.

Why the other headaches fit less well: migraine is often accompanied by photophobia, nausea, and is less likely to cause a tender, inflamed temporal artery, and tends to occur in younger patients. tension-type headaches are typically bilateral and nonlocalizing with a band-like pressure rather than a focal temporal artery finding. cluster headaches are intensely painful, usually around the eye with autonomic symptoms, and don’t present with a tender temporal artery.

In short, unilateral temple tenderness in an older patient strongly points to temporal arteritis, an urgent condition requiring immediate steroid treatment to prevent blindness, with biopsy to confirm later.