Secondary headache: giant cell arteritis, intracranial hypertension and postdural puncture

A new headache with red flags needs its cause found quickly: suspected giant cell arteritis is treated before confirmation, papilledema needs urgent imaging and venography before lumbar puncture, and refractory postdural puncture headache needs a blood patch.

1. Treat strongly suspected arteritis at once. New temporal headache with jaw claudication or a high ESR in an older adult raises suspicion; with strong suspicion, start glucocorticoids without waiting for confirmation and refer for specialist assessment within 24 hours ¹.
2. Arteritis needs a higher steroid dose. The starting dose for giant cell arteritis is 40–60 mg/day prednisone-equivalent, versus 15–25 mg/day for polymyalgia rheumatica ¹.
3. Papilledema: image within 24 hours. Urgent brain MRI should show no hydrocephalus, mass, structural or vascular lesion or abnormal meningeal enhancement; CT or MR venography is mandatory to exclude venous sinus thrombosis ².
4. Lumbar puncture comes after normal imaging. All patients with papilledema should then have opening pressure measured in the lateral decubitus position and cerebrospinal fluid contents checked ².
5. Postdural puncture headache: conservative care first. Multisociety consensus guidelines frame management around conservative measures, with an epidural blood patch for disabling or refractory symptoms ³.
6. The blood patch is the gold standard. For headache refractory to conservative measures it should be used without undue delay when there are no contraindications; the consensus guidelines do not support routine sphenopalatine ganglion block ⁴.

In suspected idiopathic intracranial hypertension, a sixth nerve palsy is compatible with the diagnosis, but involvement of other cranial nerves should prompt a search for another cause ².

• Temporal artery biopsy and other confirmatory tests proceed while glucocorticoid treatment for giant cell arteritis continues ¹.
• Interleukin-6 receptor inhibitors are an option for selected patients with polymyalgia rheumatica or giant cell arteritis ¹.
• For most patients with suspected polymyalgia rheumatica, glucocorticoids can wait until the diagnosis is confirmed ¹.
• Caffeine is one of the conservative measures for postdural puncture headache; the sphenopalatine ganglion block has weaker evidence ⁴.
• Venography in suspected intracranial hypertension is done within 24 hours, alongside MRI, to exclude cerebral venous sinus thrombosis ².
• Suspected polymyalgia rheumatica, giant cell arteritis or Takayasu arteritis should all receive specialist assessment ¹.
• Postdural puncture headache is orthostatic and results from cerebrospinal fluid leak after dural puncture ³.

• Waiting for a temporal artery biopsy before starting steroids when arteritis is strongly suspected ¹.
• Performing lumbar puncture before brain imaging and venography in papilledema ².
• Using a sphenopalatine ganglion block instead of a blood patch for refractory postdural puncture headache ⁴.
• Treating isolated polymyalgia rheumatica with the higher arteritis dose ¹.