EpistemisMandibular claudication
Specialty: Cardiovascular.
Why it occurs
- Giant cell arteritis (temporal arteritis)
- Severe atherosclerotic occlusive disease of the external carotid or internal maxillary artery
- Large vessel vasculitis (Takayasu arteritis)
- Ipsilateral carotid dissection with occlusion of the maxillary branch
Initial workup
Analytical determination of erythrocyte sedimentation rate (ESR, typically >50 mm/h) and C-reactive protein (CRP); High-resolution Doppler ultrasound of the temporal arteries to identify the "halo sign" (edema of the arterial wall indicative of vasculitis); Biopsy of the temporal artery of at least 1.5 to 2 cm in length to confirm the inflammatory giant cell infiltrate and fragmentation of the internal elastic lamina; Computed tomography angiography of neck vessels if large vessel involvement is suspected.
red flags
Intense pain or fatigue in the masseter and temporalis muscles that is typically triggered by chewing solid food or speaking and that subsides completely with rest, associated with recent onset unilateral headache of a lancinating or dull nature, painful hypersensitivity of the scalp (especially when combing one's hair), pain and stiffness in the shoulder and pelvic girdle (concomitant polymyalgia rheumatica), sudden and unilateral loss of vision (amaurosis fugax or anterior ischemic optic neuropathy), or thickening and absence of pulse of the superficial temporal artery. Requires immediate immunosuppressive treatment to avoid permanent blindness.
Standard management
- Methylprednisolone — Systemic glucocorticoid indicated urgently if there are associated visual symptoms; 500 to 1000 mg intravenously daily for 3 consecutive days before switching to oral therapy
- Prednisone — Oral glucocorticoid of initial choice in the absence of amaurosis; 1 mg/kg/day, typically 40 to 60 mg per day orally for 2 to 4 weeks, followed by a very gradual and prolonged taper over months
- Tocilizumab — anti-IL-6 receptor monoclonal antibody, indicated in combination with glucocorticoids to reduce the cumulative dose of steroids and prevent relapses; 162 mg subcutaneously once a week
- Acetylsalicylic acid (indicated to reduce the risk of thrombotic occlusion and cerebrovascular or visual events; 100 mg once daily orally).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Cardiovascular
- Listed causes
- 4
- Treatment options
- 4