Clinical assessment is the cornerstone of diagnosis in headache but can prove misleading when more than one type of headache coexists. We describe two patients with phenotypically classical cluster headache who were found to have giant cell arteritis. Case 1 was a 52-year-old lady who presented with episodic, intense left eye pain accompanied by ipsilateral lacrimation and a transient Horner's syndrome; she responded partially to treatment with topiramate and then verapamil but went on to develop diffuse shoulder girdle pains and a left subclavian artery stenosis with an ESR of 47. Treatment with prednisolone 40 mg produced prompt resolution of her systemic symptoms, but only transient relief of her cluster headaches which have subsequently been poorly responsive to medical therapies. Case 2 was a 58-year-old gentleman who presented with severe episodic unilateral orbital headaches in the evenings, associated with scleral injection, swelling, and a left Horner's syndrome. Again it was the ESR that raised concern regarding giant cell arteritis, which was confirmed on temporal artery biopsy. Prednisolone provided good acute relief of symptoms. To our knowledge, only two other cases of giant cell arteritis presenting in patients with cluster headaches have been reported in the literature. The basis of the association is not clear. As has previously been suggested, ESR is a helpful investigation in such instances as it is seldom raised in isolated cluster headache.
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