Giant cell arteritis (temporal arteritis)
Giant cell arteritis is inflammation of the wall of large and medium-sized arteries, most often the ones that run under the skin of the temples.
On this page
- If vision blurs or goes, the clock runs in hours
- A new headache in the temple: how it usually starts
- Shoulders and hips in the morning: the link with polymyalgia rheumatica
- What the blood shows, and what it does not
- Ultrasound and temporal artery biopsy
- Treatment starts at once, before anything is confirmed
- Steroids for the long haul: tapering, bones and blood sugar
- When the disease comes back
- Online consultation
Medicines commonly prescribed for Giant cell arteritis (temporal arteritis)
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: ORAL SOLUTION/SUSPENSION, 4 mg/mlActive substance: prednisoloneManufacturer: Laboratorio Aldo Union S.L.Prescription requiredDosage form: ORAL SOLUTION/SUSPENSION DROPS, 13.3 mg prednisolone estragelate/mlActive substance: prednisoloneManufacturer: Laboratorios Sonphar S.L.Prescription required
Giant cell arteritis is inflammation of the wall of large and medium-sized arteries, most often the ones that run under the skin of the temples. Hence the other name it goes by: temporal arteritis. It affects people over fifty, and it almost always announces itself with a headache that was not there before. It is one of the very few rheumatic diseases treated as an emergency: an inflamed artery can shut off the blood supply to the optic nerve, and sight is then lost suddenly, painlessly and, as a rule, for good. That loss can be prevented; it can almost never be reversed. So this page begins not with definitions but with the thing that cannot wait until morning.
If vision blurs or goes, the clock runs in hours
Any new disturbance of vision in someone with a headache in the temple means seeking help immediately, within the hour, not booking an appointment for next week. The things that count are these:
- sight in one eye went for a few seconds or minutes and came back, like a curtain coming down and lifting again;
- double vision;
- part of the field of vision has dropped out, or turned grey or dark;
- sight in one eye has fallen sharply or gone altogether, usually with no pain in the eye itself.
A brief loss of vision matters not in itself but as a warning: within days, sometimes hours, it is followed by permanent blindness in that eye. And if one eye has already gone, the other can follow within twenty-four hours if nothing is done.
In practice this means going to emergency care or calling an ambulance — across much of Europe the single emergency number is 112 — and saying it plainly: "suspected temporal arteritis, my vision has changed." That wording changes the order of things: the person is seen the same day and treatment is started at once, without waiting for blood results or for a rheumatologist to attend.
A new headache in the temple: how it usually starts
The classic opening is this. Someone past fifty, who has hardly ever suffered headaches, develops a constant dull or burning pain over the temple, usually on one side. Painkillers barely touch it, or help only briefly. What matters is not how severe the pain is but that it is new: at this age a headache unlike anything before it always deserves a conversation with a doctor.
Alongside it come the things people do not think of as symptoms and do not mention until asked:
- A tender scalp. It hurts to comb the hair, to put glasses on, to lie on that side of the head. The skin over the temple can be sore to the lightest touch.
- Jaw pain on chewing. The most telling sign of the disease. The person starts eating and, after half a minute or so, an aching tiredness builds in the jaw — sometimes in the tongue — forcing a pause; after resting, chewing is possible again. This is not toothache and not joint pain: it comes on with the work itself, because the chewing muscles are not getting enough blood.
- A firm, knotted, tender artery at the temple. Sometimes it can be seen and felt, and the pulse in it is weak or absent.
- Feeling generally unwell. Weakness, exhaustion, loss of appetite and weight, night sweats, a low fever with no obvious cause, low mood. Sometimes this is where it all begins, and the person is investigated for weeks for unexplained fever and weight loss.
Less often there is pain in the tongue while talking, neck pain, weakness and aching in the arms on exertion, or a difference in blood pressure between the two arms — a sign that the inflammation has reached beyond the temples into larger vessels.
Shoulders and hips in the morning: the link with polymyalgia rheumatica
In a proportion of people, temporal arteritis travels with polymyalgia rheumatica, and often it is the polymyalgia that comes first. It looks very characteristic: in the morning the shoulders, neck, upper back and hips ache and will not do as they are told. The stiffness lasts not five minutes but half an hour, an hour or longer. Lifting the arms to comb the hair or reach a shelf is hard, getting out of a chair or a bath is hard, turning over in bed is hard. By evening it eases, and next morning it starts again.
This is not wear and tear and it is not simply age. Polymyalgia is the same inflammation in a different place, and it is treated with the same steroids at lower doses. The link works both ways. If polymyalgia has already been diagnosed and a headache in the temple appears, or a tender scalp, or jaw pain on chewing, or anything at all with the vision, the doctor needs to hear about it urgently rather than at the next routine review. And the other way round: morning stiffness in the shoulders and hips in someone with a new headache is a strong argument for this diagnosis.
What the blood shows, and what it does not
The first things looked at are the markers of inflammation: the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). In giant cell arteritis they are usually sharply raised, and this is one of the situations where a very high ESR really does mean something. The full blood count often shows mild anaemia and a high platelet count, and liver figures may be disturbed.
But a normal ESR and CRP do not rule the diagnosis out. In a small proportion of people the disease runs with quiet blood tests, and those cases are no milder than the rest — they lose their sight too. If the picture is typical (the age, the new temple headache, jaw pain on chewing, a tender scalp), a normal result should reassure neither the patient nor the doctor. The reverse is equally true: a high ESR on its own proves nothing, since infections, tumours and a dozen other things push it up.
The main value of these tests lies elsewhere: they give a starting point against which to judge later whether the treatment is working and whether the inflammation has returned as the dose comes down.
Ultrasound and temporal artery biopsy
An ultrasound scan of the temporal and axillary arteries is quick and painless, and where there is inflammation it shows a characteristic thickening of the vessel wall. In many centres it is the first test, and it is done in the first few days if possible, because steroids gradually smooth the picture out.
Biopsy of the temporal artery remains the standard for confirming the diagnosis: under local anaesthetic, through a small cut beside the temple, a short piece of artery is taken and examined under the microscope. It harms neither vision nor the blood supply to the head, as neighbouring vessels take over the work.
Two things about the biopsy are worth knowing. First: treatment is not held up waiting for it. Steroids are started as soon as there is reasonable suspicion, and the biopsy is done with treatment already under way, because the changes in the wall persist long enough to be seen. Second: a negative biopsy does not rule the diagnosis out either. The inflammation is patchy along the artery, and the sample may come from a healthy stretch; where the clinical picture is convincing, treatment carries on despite a clear biopsy. To assess the larger vessels, further imaging is sometimes added, and that is for the specialist to decide.
Treatment starts at once, before anything is confirmed
The mainstay of treatment is glucocorticoids — steroid anti-inflammatory medicines. A high dose by mouth is started; if vision has already suffered or is at risk, treatment begins in hospital by drip. Doses are set by the doctor and must not be altered on your own.
They work fast and convincingly: the headache and the tender scalp usually settle within a day or two, and the general state of things improves within a few days. That clear improvement is in itself indirect support for the diagnosis. But one thing is worth understanding in advance: steroids protect the sight that remains and almost never bring back sight already lost. That is the whole point of the hurry.
To avoid keeping anyone on high doses for years, other medicines are often added that allow the steroid to come down sooner and more safely: this may be a conventional agent such as methotrexate, or a biological medicine that blocks interleukin-6. They are used where there are frequent relapses, where steroids are poorly tolerated, or where there is diabetes or severe osteoporosis. Low-dose aspirin used to be recommended to everyone; today the decision is made case by case, weighing the risk of clots against the risk of bleeding — a question to discuss with the doctor rather than settle alone.
Steroids for the long haul: tapering, bones and blood sugar
Treatment is measured not in weeks but in months and usually in years: a high dose until the symptoms are gone, then a slow, stepwise reduction guided by how the person feels and by blood tests. It commonly takes a year or two, and some people stay on a small maintenance dose for a long time.
Steroids are never stopped abruptly. After a long course, the adrenal glands work at half strength, and a sudden withdrawal can bring on a serious state with falling blood pressure, vomiting and weakness. That includes the day the tablets simply run out. Carry a card or a note saying you take steroids: it matters to any doctor who has to treat you in an emergency. With a severe infection, an injury or an operation the dose is sometimes raised temporarily, and that too is the doctor's call.
Side effects are planned for from day one, not dealt with once they arrive:
- Bones. Steroids speed up loss of bone. Calcium and vitamin D are usually started straight away, and where the fracture risk is high, medicines that strengthen bone; measuring bone density at the outset is useful.
- Blood sugar. Steroids push it up. In someone with diabetes the treatment nearly always needs revising; in everyone else sugar is checked regularly, because it can rise for the first time.
- Blood pressure and weight. Appetite grows, weight goes up, blood pressure creeps up — all of it watched and treated in the usual ways. Where needed, a medicine to reduce stomach acid is added.
- Infections. Immunity is lowered, and steroids blunt fever, so an infection can look deceptively mild. Vaccination is worth discussing with the doctor.
- Eyes, sleep and mood. Over time the risk of cataract and glaucoma rises, so eye checks are needed. Sleeplessness and irritability on high doses are common and should be mentioned rather than endured.
When the disease comes back
Relapses as the dose comes down happen to a good proportion of people and do not mean the treatment has failed. The same signs return as at the start: pain in the temple, jaw pain on chewing, stiff shoulders and hips, weakness, fever. The rule is simple: if the old symptoms return, see a doctor without waiting for the scheduled review — and with any disturbance of vision, immediately. Usually the dose goes back up a step and comes down more slowly afterwards.
People who have had giant cell arteritis are more likely to develop widening of the aorta, which can give no sign of itself for years, so follow-up continues even after the steroids have been stopped. Treated, the disease does not appreciably shorten life; its main threat remains the one it started with.
Online consultation
The acute situation is not for a remote appointment: if vision blurs, disappears or doubles, what is needed is urgent care in person within the hour. But a remote consultation has three clear uses here. The first is making sense of a new headache in someone over fifty: the doctor will ask about the scalp, the jaw while chewing, the shoulders and the general state of things, and will say whether this needs investigating urgently. That conversation is what most often gets a person assessed in time, including those who have spent years being told their headache is tension or the neck. The second is supporting a long steroid course: how the taper is going, what to do about a missed dose, which blood tests to have and how often, what to do about sugar, blood pressure, weight and bones. The third is sorting out confusing situations: normal blood tests with suspicious symptoms, a negative biopsy, symptoms returning as the dose falls.
This material is for information only and does not replace medical advice.
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