Date of last review: Due to be updated

Differential diagnosis

  • Migraine
  • Analgesic induced headache
  • Cluster headache
  • Trigeminal neuralgia

Possible management by Optometrist

Treatment

  • None

Advice

  • Urgent referral to the GP same day 
  • Advice to General Practice
    • Measure CRP (ESR if CRP not possible) and full blood count prior to starting treatment
    • Start prednisolone
      • 60mg daily one week
      • 45mg daily one week
      • 30mg daily one week
      • 20mg daily one week
      • 15mg daily for one week
    • Monitor response day 1 or 2 after starting 60mg of prednisolone
      • Symptoms should have dramatically responded
      • Inflammatory markers (CRP, ESR (delayed), platelets should have significantly improved
      • Thereafter monitor response by symptoms and inflammatory markers every few months until after treatment ends
    • If no, or poor response, reconsider diagnosis
    • Reconsider management next when patient down to 15mg daily
    • If there has been a rapid improvement in symptoms and inflammatory markers, then reduce prednisolone to
      • 12.5 mg daily for one week
      • then 10mg daily for one month
      • Reduce prednisolone thereafter by 1mg a month to 5mg daily.
      • Stay on 5mg daily until anniversary
      • Then reduce by 1mg a month to zero
    • If the response has been slower then
      • Reduce prednisolone by 1mg a month to 5mg daily.
      • Stay on 5mg daily until anniversary
      • Then reduce by 1mg a month to zero
    • Prescribe omeprazole 20mg daily until down to less than 10mg of prednisolone
    • Start on Alendronic Acid with adequate Calcium and Vitamin D supplementation
  • GP to commence oral steroids and refer to hospital for temporal artery ultrasound or biopsy (may not be performed by ophthalmology department if no visual symptoms: check protocol with local hospital)
  • If same day GP review not possible, refer urgently to ophthalmology or rheumatology, according to local guidelines.

Management Category

  • Urgent referral to GP
  • Urgent referral to ophthalmology or rheumatology, according to local guidelines

Possible management by Ophthalmologist

  • Steroids (with gastric protection)
  • Temporal artery ultrasound or biopsy to confirm the diagnosis