giant cell arteritis ( gca ) , also known as temporal arteritis ( ta ) , is an autoimmune disease and the most common form of vasculitis in individuals over the age of 50 . it is regarded as one of the possible underlying causes of secondary headaches in the elderly . in terms of harmful effects , it is considered a neurological emergency and it is recommended that upon clinical suspicion , treatment be initiated promptly to prevent irreversible damage . gca involves medium and large arteries in the head , neck , and upper part of the body . branches of the external and internal carotid arteries are particularly susceptible and their involvement leads to the classic manifestations of visual loss , headache , scalp tenderness , and jaw claudication . jaw claudication is a prominent symptom of gca described as pain in the jaw during mastication or speaking and results from ischemic maxillary artery supplying the masseter muscles . the headache is described by patients as throbbing in nature and usually occurs in both temples . the prevalence is higher in scandinavian countries , which is twice as much as other european countries . the age of onset of gca is usually greater than 50 years ; however , it is most commonly seen in patients between 70 and 80 years of age . females have a higher incidence than males with a female to male ratio of 3:1 . tension - type headache is classified by the international headache society as a primary headache . this pain originates typically in the forehead and bilaterally spreads to the occiput , ultimately reaching the neck muscles . the pain is classified under the category of tightening and non - pulsating and is not accompanied by nausea or any other elements of migraine symptomology . due to its nature as a primary type , tension - type headaches are not caused by any endogenous neural dysfunction or disease , whereas gca is caused by inflammation of the arteries . a detailed history and physical examination is essential for accurate diagnosis , especially if gca presents with atypical features . since gca is a treatable condition , it is important to make the correct diagnosis to prevent the potential complication of irreversible vision loss . corticosteroids remain the gold - standard treatment for gca . herein , we report a case of an elderly female , who presented with clinical features akin to tension - type headache one year prior to her correct diagnosis of gca . an 81-year - old woman was referred to our clinic with the chief complaint of a newly developed onset headache , which occurred on a daily basis and was localized in the left occipital area . however , a few months later , the pain involved the parietal region as well . the pain was nocturnal , causing her to wake up 3 to 4 times on average per night . furthermore , the patient described the headaches as throbbing in nature , no nausea or vomiting , no history of light sensitivity , and no aura or focal motor or sensory symptoms . her neurological examination was unremarkable . a ct scan of the head displayed moderate cerebral atrophy but was otherwise unremarkable . she continued to use over - the - counter analgesic medications with temporary relief of her headaches . one year later , she was presented to the ophthalmology clinic with left visual disturbances . in addition to this , she had symptoms of bilateral jaw claudication and an elevated crp of 59 . she subsequently underwent a temporal artery biopsy on the left side , which was positive for gca . she was treated with corticosteroids and responded well to the treatment ; however , her visual acuity did not improve . the inflammation of large- and medium - sized arteries in gca is thought to be due to an antigen - mediated autoimmune response . clinically , gca has a broad spectrum of associated symptoms , with the most common being headache ( 70 - 90% ) , jaw claudication ( 40 - 60% ) , transient ischemic attack ( 4% ) , neck pain , scalp tenderness , and visual disturbances . the american college of rheumatology ( acr ) has devised a set of criteria for temporal arteritis which requires that at least three of the following conditions be met : ( i ) patient age > 50 years , ( ii ) new onset of headache , ( iii ) temporal artery tenderness , ( iv ) elevated esr , and ( v ) abnormal findings of temporal artery biopsy . however , acr criteria are utilized best for classification purposes and are not validated for use in clinical diagnosis . interestingly , our patient had only occipital pain without developing any temporal pain . this is an atypical presentation of gca , which potentially contributed to the delayed diagnosis and her subsequent serious complication of irreversible visual loss . the visual symptoms of gca can include amaurosis , diplopia , and visual loss which are due to ischemic optic neuropathy , and visual symptoms may develop months after the initial symptoms onset . about 20 to 50% of patients develop ischemia of the optic nerve , leading to irreversible blindness . before other manifestations of gca are experienced , patients may complain of pain in their teeth , jaw , ear , or zygoma . corticosteroids are administered and improvements in systemic symptoms and normalization of crp or esr are noted . the duration of corticosteroid therapy is variable and can extend to several years depending upon patient needs . eular guidelines provide several recommendations and mention other pharmacological therapies that may be helpful in the treatment of gca . furthermore , there is evidence showing a rapid response with the use of tocilizumab , an il-6r antagonizing monoclonal antibody , including normalization of gca symptoms and inflammatory markers . despite these encouraging results , randomized control trials are underway to fully confirm its efficacy in the treatment of gca . gca as a secondary headache has been subject to misdiagnoses when presented with atypical features that are more representative of other disease states as seen in our case . this has been supplemented through further evidence of other gca diagnostic dilemmas in the literature . one case report presented an elderly patient suffering from orofacial pain , which is an atypical feature of gca . in addition , kraemer et al . emphasized the importance of greater analysis into individual gca symptoms . this was elucidated in their case report as the reduction of jaw opening ( i.e. an atypical feature ) in their patient led to the misdiagnosis of gca as occipital neuritis and craniomandibular dysfunction . furthermore , gca can also be associated with other diseases such as takayasu arteritis . despite the literature being laden with several diagnostic dilemmas concerning gca , our case report is unique in terms of being the only one where gca was misdiagnosed as tension - type headache . however , our case presents an opposite dilemma , as our patient presented with atypical features of gca that were more characteristic of tension - type headache . hence , it is important to be aware of overlapping features of these conditions to prevent misdiagnoses . furthermore , a lack of clinical findings concerning gca in general can lead to an increase in misdiagnosed cases . most importantly , there is a lack of robust findings in literature concerning cases where gca presents itself as tension - type headache , which underscores the distinctiveness of our case . lastly , our case emphasizes the importance of considering gca as a potential diagnosis for elderly patients with new onset headache located in a non - temporal region . our patient had only occipital / parietal pain throughout the course of the disease , without the involvement of any temporal pain . in order to resolve similar future diagnostic dilemmas , we recommend these patients should have a full workup for gca conducted as well as checking their esr and crp levels . this may prevent the severe complications of irreversible vision loss , as was seen in our case . although the diagnosis of gca can be impeded due to the conflicts of its clinical presentation with several other neurological conditions , this unique case highlights the importance of considering gca and its atypical characteristics when patients present with features similar to tension - type headache .
giant cell arteritis ( gca ) or temporal arteritis ( ta ) is an autoimmune disease and the most common type of vasculitis in the elderly . 
 it causes inflammation of the medium and large arteries in the upper part of the body . 
 gca is an under - recognized cause of   head aches in the elderly , especially when it presents itself with atypical features , resulting in delayed or incorrect diagnosis . 
 since gca is a treatable condition , an accurate diagnosis is crucial to prevent the most serious complication of cga , permanent vision loss . 
 the diagnosis can be further complicated as gca may present with features of other painful neurological conditions . 
 the present case is an 81-year - old woman diagnosed with gca , who initially presented with features similar to tension - type headache . due to overlapping features of these conditions , 
 the diagnosis of gca was delayed , resulting in irreversible vision loss . 
 although previous research highlights diagnostic dilemmas featuring gca and other disease states , this case is exclusive in describing a unique dilemma where tension - type headache mimics gca .