Headache: Geriatric Headaches
Temporal Arteritis continued...
CRP is an acute-phase plasma protein from the liver. As with the ESR, elevation of CRP levels is nonspecific and can be seen with numerous disorders. The CRP level is not influenced by various hematologic factors or age and is more sensitive than the ESR for the detection of TA. The combination of ESR and CRP levels gives the best specificity (97%).
The diagnosis is made with certainty when a superficial temporal artery biopsy demonstrates necrotizing arteritis characterized by a predominance of mononuclear cell infiltrates or a granulomatous process with multinucleated giant cells. The false negative rate of temporal artery biopsies ranges from 5% to 44%.
In patients without contraindications, treatment is typically started with prednisone at a dosage of 40 to 80 mg a day. The headache will often improve within 24 hours. The initial dose is maintained for about 4 weeks and then slowly reduced over many months, depending on the clinical effect, the ESR, and the occurrence of side effects. Long-term treatment is often required. Delay in treatment of temporal arteritis can result in permanent blindness.
Ninety percent of cases of trigeminal neuralgia (also known as tic douloreux) begin after age 40. About 80% of cases result from vascular compression of the trigeminal nerve at the root entry zone, most commonly by a branch of the superior cerebellar artery. About 5% of cases are caused by tumors. The pain is a severe, sharp, shooting, or electric shock-like sensation lasting seconds to 2 minutes. It is usually in a unilateral maxillary or mandibular trigeminal distribution and uncommonly in the ophthalmic division.
In about 90% of cases of trigeminal neuralgia, the patient has trigger zones, usually in the central part of the face around the nose and lips. Normally nonpainful stimuli in these zones can trigger pain. Stimuli can include talking, chewing, washing the face, brushing the teeth, shaving, facial movement, and cold air. After a paroxysm of pain, there is a refractory period lasting up to several minutes during which stimulation of the trigger zone will not trigger pain. Facial grimacing or spasm may accompany the pain. Between painful paroxysms, the patient is usually pain free, although dull aching may persist for a few minutes after attacks of long duration or multiple clustered attacks. Multiple attacks may occur for weeks or months. About 50% of patients with trigeminal neuralgia will have spontaneous remissions for at least 6 months. Physical examination is usually normal except for trigger zones, although up to 25% of patients will have sensory loss. Patients usually see dentists before seeking medical evaluation as they may think they have a cavity.
Medications that may be effective against trigeminal neuralgia, alone or sometimes in combination, include carbamazepine, oxcarbazepine, baclofen, phenytoin, clonazepam, divalproex sodium, topirimate, lamotrigine, gabapentin, and pimozide. About 30% of patients are nonresponsive to medical treatment but may respond to one of the many surgical approaches available.