The case below is followed by a choice of diagnoses. Select the answer choice that best describes this patient’s condition.
A 65-year-old executive assistant with a history of hypothyroidism, hypertension and osteoarthritis presented to the emergency department with three days of severe headache. She described the pain as sharp, pulsating, and localized to the right side of her head and radiating to her neck. She has never experienced a headache like this before and had previously been feeling well but reports some malaise for the past week. She had driven to the grocery store one day prior without any difficulty and denied visual changes, aura or photophobia. She reported no fever, confusion or weakness in her extremities. After detailed questioning she recalled that this morning during breakfast her right jaw was aching while chewing. She took several tablets of acetaminophen without relief prior to coming to the ER.
Vital signs were stable and her examination revealed an elderly woman in mild distress. She had no head trauma and no tenderness to palpation of the head and neck. Her neck was supple with good range of motion. Pupils were equal and reactive and extraocular muscles were intact. Visual fields were full by confrontation and fundoscopy revealed sharp optic discs without papilledema. There were no carotid bruits. Heart, lung and abdominal examinations were normal. Her extremities were warm and well-perfused without rash. Pulses were 2+ throughout. She was alert and able to follow commands. Cranial nerves were intact and strength, sensation, reflexes, tone, and bulk were normal and symmetric. Her laboratory testing revealed normal serum chemistries, a normal white blood count, but erythrocyte sedimentation rate was 119 mm/hr (normal <31) and C-reactive protein of 6.9 mg/dL (normal <0.9). CT scan of the head showed no acute intracerebral hemorrhage.
Which diagnosis is most likely?
A. Cervical radiculopathy
B. Temporal arteritis
C. Migraine headache
D. Tension-type headache
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