Prospective cohort study of daily alcoholic beverage intake as a potential trigger of headaches among adults with episodic migraine.

PURPOSE: To determine whether alcohol intake is associated with occurrence of headaches on the following day. METHODS: In this prospective cohort study, adults with episodic migraine completed electronic diaries every morning and evening for at least six weeks in March 2016-October 2017. Every day, participants reported alcohol intake, lifestyle factors, and details about each headache. We constructed within-person fixed-effect models adjusted for time-varying factors to calculate odds ratios for the association between 1,2,3,4, or 5+ servings of alcohol and headache the following day. We also calculated the adjusted risk of headache the following day for each level of intake. RESULTS: Among 98 participants who reported 825 headaches over 4,467 days, there was a statistically significant linear association (p-trend = 0.03) between alcohol and headache the following day. Compared to no alcohol, 1-2 servings were not associated with headaches, but 5+ servings were associated with a 2.08-fold (95% confidence interval [CI] 1.16-3.73) odds of headache. The adjusted absolute risk of headaches was 20% (95%CI 19%-22%) on days following no alcohol compared with 33% (95%CI 22%-44%) on days following 5+ servings. CONCLUSION: 1-2 servings of alcoholic beverages were not associated with higher risk of headaches the following day, but 5+ servings were associated with higher risk. KEY MESSAGES 1-2 servings of alcoholic beverages were not associated with a higher risk of headaches on the following day, but higher levels of intake may be associated with higher risk. Five or more servings were associated with 2.08 times (95% confidence interval 1.16-3.73 the odds of headache on the following day. The adjusted absolute risk of headaches was 20% (95%CI 19%-22%) on days following no alcohol consumption compared with 33% (95% CI 22%-44%) on days following 5+ servings.

Association of EPAS1 and PPARA Gene Polymorphisms with High-Altitude Headache in Chinese Han Population.

BACKGROUND: High-altitude headache (HAH) is the most common complication after high-altitude exposure. Hypoxia-inducible factor- (HIF-) related genes have been confirmed to contribute to high-altitude acclimatization. We aim to investigate a possible association between HIF-related genes and HAH in the Chinese Han population. METHODS: In total, 580 healthy Chinese Han volunteers were recruited in Chengdu (500 m) and carried to Lhasa (3700 m) by plane in 2 hours. HAH scores and basic physiological parameters were collected within 18-24 hours after the arrival. Thirty-five single nucleotide polymorphisms (SNPs) in HIF-related genes were genotyped, and linkage disequilibrium (LD) was evaluated by Haploview software. The functions of SNPs/haplotypes for HAH were developed by using logistic regression analysis. RESULTS: In comparison with wild types, the rs4953354 "G" allele (P=0.013), rs6756667 "A" allele (P=0.013), rs6756667 "A" allele (EPAS1, and rs6520015 "C" allele in PPARA (P=0.013), rs6756667 "A" allele (PPARA (P=0.013), rs6756667 "A" allele (EPAS1, and rs6520015 "C" allele in PPARA (P=0.013), rs6756667 "A" allele (. CONCLUSIONS: EPAS1 and PPARA polymorphisms were associated with HAH in the Chinese Han population. Our findings pointed out potentially predictive gene markers, provided new insights into understanding pathogenesis, and may further provide prophylaxis and treatment strategies for HAH.EPAS1, and rs6520015 "C" allele in PPARA (.

Influence of culture on pain comorbidity in women with and without temporomandibular disorder-pain.

Evidence on cultural differences in prevalence and impact of common chronic pain conditions, comparing individuals with temporomandibular disorders (TMD) versus individuals without TMD, is limited. The aim was to assess cross-cultural comorbid pain conditions in women with chronic TMD pain. Consecutive women patients (n = 122) with the index condition of chronic TMD pain diagnosed per the research diagnostic criteria for TMD and TMD-free controls (n = 121) matched for age were recruited in Saudi Arabia, Italy and Sweden. Self-report questionnaires assessed back, chest, stomach and head pain for prevalence, pain intensity and interference with daily activities. Logistic regression was used for binary variables, and ancova was used for parametric data analysis, adjusting for age and education. Back pain was the only comorbid condition with a different prevalence across cultures; Swedes reported a lower prevalence compared to Saudis (P < 0·01). Saudis reported higher prevalence of work reduced >50% due to back pain compared to Italians or Swedes (P < 0·01). Headache was the most common comorbid condition in all three cultures. The total number of comorbid conditions did not differ cross-culturally but were reported more by TMD-pain cases than TMD-free controls (P < 0·01). For both back and head pain, higher average pain intensities (P < 0·01) and interference with daily activities (P < 0·01) were reported by TMD-pain cases, compared to TMD-free controls. Among TMD-pain cases, Italians reported the highest pain-related disability (P < 0·01). Culture influences the associated comorbidity of common pain conditions. The cultural influence on pain expression is reflected in different patterns of physical representation.

Headaches in multiple sclerosis: Cross-sectional study of a multiethnic population.

OBJECTIVES: Headaches in MS are common, but there is little data on the influence of race, comorbidities, MS disability and socioeconomic issues on headaches, especially migraine. We aimed at looking at prevalence and type of headache across a multiethnic MS population, and relationship between MS related clinical factors and migraine. PATIENTS AND METHODS: This is a cross-sectional study of 233 MS patients at two clinical sites, one at a county hospital, and the other a private academic center clinic. We collected demographic data, MS characteristics, and headache histories using validated survey instruments including Headache Impact Test (HIT-6) and Patient Health Questionnaire-9 (PHQ-9). The relationship between MS and migraine was examined using logistic regression. RESULTS: Majority of our patients were female (N=156, 67%), average age 44 years, with relapsing remitting MS (N=214, 92%). Our cohort was multi-ethnic predominantly Whites (N=106, 46%) and Hispanics (N=87, 37%). Public sector patients were significantly disadvantaged in socioeconomic measures (p<0.0001) and younger (40 vs 47 yrs, p<0.0001), compared to the private sector patients who had a higher MS burden. Headaches were common, regardless of sector (N=115, 49.4%), the most common type being migraine (N=83, 36%). Chronic migraine was more common among Hispanics (82%) than Whites (18.2%) (p=0.012). Headache impact on daily life, measured by HIT-6 score (p=0.006) and PHQ-9 score (p=0.004) were significantly higher in the public sector. After controlling for income and education, female gender (OR 2.59, 95% CIs 1.312-5.127) and ambulatory disability were found to be more likely to suffer from migraines. CONCLUSION: Headache, especially migraine is common among MS patients regardless of socio-economic status and treatment setting. Female MS patients with walking disability and longer disease duration tend to get migraines. Hispanic MS patients have a higher likelihood of suffering from chronic migraines. Thorough headache evaluation and headache treatment are essential to comprehensive MS care.

Coccidioidomycosis: Experience From a Children's Hospital in an Area of Endemicity.

The incidence of coccidioidomycosis is increasing, and published pediatric experience is limited. This study further characterizes pediatric coccidioidomycosis by describing experience with 64 patients cared for at Children's Hospital of Los Angeles over 20 years, with focus on sites of involvement and severity, as well as serologic profiles of affected children.

The Prevalence and Characteristics of Primary Headache and Dream-Enacting Behaviour in Japanese Patients with Narcolepsy or Idiopathic Hypersomnia: A Multi-Centre Cross-Sectional Study.

BACKGROUND: Because the prevalence and characteristics of primary headache have yet to be thoroughly studied in patients with hypersomnia disorders, including narcolepsy and idiopathic hypersomnia, we examined these parameters in the Japanese population. METHODS: In a multicentre cross-sectional survey, among 576 consecutive outpatients with sleep disorders, 68 narcolepsy patients and 35 idiopathic hypersomnia patients were included. Additionally, 61 healthy control subjects participated. Semi-structured headache questionnaires were administered to all participants. RESULTS: The patients with narcolepsy (52.9%) and idiopathic hypersomnia (77.1%) more frequently experienced headache than the healthy controls (24.6%; p<0.0001). The prevalence rates were 23.5%, 41.2% and 4.9% for migraine (p<0.0001) and 16.2%, 23.5% and 14.8% (p = 0.58) for tension-type headache among the narcolepsy patients, the idiopathic hypersomnia patients and the control subjects, respectively. Those who experienced migraine more frequently experienced excessive daytime sleepiness, defined as an Epworth Sleepiness Scale score of ≥10, than those who did not experience headache among the patients with narcolepsy (93.8% vs. 65.6%, p = 0.040) and idiopathic hypersomnia (86.7% vs. 37.5%, p = 0.026). Dream-enacting behaviour (DEB), as evaluated by the rapid eye movement sleep disorders questionnaire, was more frequently observed in the narcolepsy patients than in the idiopathic hypersomnia patients and the control subjects. An increased DEB frequency was observed in the narcolepsy patients with migraines compared to those without headache. CONCLUSIONS: Migraines were frequently observed in patients with narcolepsy and idiopathic hypersomnia. DEB is a characteristic of narcolepsy patients. Further studies are required to assess the factors that contribute to migraines in narcolepsy and idiopathic hypersomnia patients.

Estimating the prevalence and burden of major disorders of the brain in Nepal: methodology of a nationwide population-based study.

BACKGROUND: The major disorders of the brain (MDBs), in terms of their prevalence and the burdens of ill health, disability and financial cost that they impose on individuals and society, are headache, depression and anxiety. No population-based studies have been conducted in Nepal. AIM: Our purpose was to assess the prevalence and burden attributable to MDBs in Nepal in order to inform health policy. Here we report the methodology. METHODS: The unusual sociocultural diversity and extreme geographical variation of the country required adaptation of standard methodology. We ran pre-pilot and pilot studies before embarking on the main study. The study design was cross-sectional. The population of interest were adults aged 18-65 years who were Nepali speaking and living in Nepal. We selected, employed and trained groups of interviewers to visit randomly selected households by cold-calling. Households were selected from 15 representative districts out of 75 in the country through multistage cluster sampling. One participant was selected randomly from each household. We used structured questionnaires (the HARDSHIP questionnaire, Hospital Anxiety and Depression Scale, and Eysenck Personality Questionnaire -Neuroticism), culturally adapted and translated into Nepali. We recorded blood pressure, weight, height and waist circumference, and altitude of each household. We implemented various quality-assurances measures. RESULTS: We completed the survey in one month, prior to onset of the monsoon. Among 2,210 selected households, all were contacted, 2,109 were eligible for the study and, from these, 2,100 adults participated. The participation rate was 99.6%. CONCLUSION: Standard methodology was successfully applied in Nepal, with some adaptations. The sociocultural and extraordinary geographic diversity were challenging, but did not require us to compromise the scientific quality of the study.

National women's knowledge of stroke warning signs, overall and by race/ethnic group.

BACKGROUND AND PURPOSE: Recognition of stroke warning signs may reduce treatment delays. The purpose of this study was to evaluate contemporary knowledge of stroke warning signs and knowledge to call 9-1-1, among a nationally representative sample of women, overall and by race/ethnic group. METHODS: A study of cardiovascular disease awareness was conducted by the American Heart Association in 2012 among English-speaking US women ≥25 years identified through random-digit dialing (n=1205; 54% white, 17% black, 17% Hispanic, and 12% other). Knowledge of stroke warning signs, and what to do first if experiencing stroke warning signs, was assessed by standardized open-ended questions. RESULTS: Half of women surveyed (51%) identified sudden weakness/numbness of face/limb on one side as a stroke warning sign; this did not vary by race/ethnic group. Loss of/trouble talking/understanding speech was identified by 44% of women, more frequently among white versus Hispanic women (48% versus 36%; P<0.05). Fewer than 1 in 4 women identified sudden severe headache (23%), unexplained dizziness (20%), or sudden dimness/loss of vision (18%) as warning signs, and 1 in 5 (20%) did not know 1 stroke warning sign. The majority of women said that they would call 9-1-1 first if they thought they were experiencing signs of a stroke (84%), and this did not vary among black (86%), Hispanic (79%), or white/other (85%) women. CONCLUSIONS: Knowledge of stroke warning signs was low among a nationally representative sample of women, especially among Hispanics. In contrast, knowledge to call 9-1-1 when experiencing signs of stroke was high.

Chucaque and social stress among Peruvian highlanders.

Highland agriculturalists complain of the cultural syndrome chucaque in the Peruvian Andes. The first aim of this research was to ethnographically document cases of a cultural syndrome utilizing theoretical elements borrowed from cognitive anthropology. Another aim was to use case-control sampling to determine if there was a relationship between higher social stress levels and the development of a cultural syndrome. The research reported here integrated qualitative and quantitative methods. The social stress gauge developed by Rubel et al. () was adapted to the Andean cultural environment and utilized to assess highland social stressors. Chucaque was found to be locally defined as a specific type of head pain commonly associated with the episode of a traumatic event. Chucaque and household social stress levels were found to be significantly related, especially when the ratio of males to females, which often was imbalanced, was included in the analysis.

Energy drinks and other dietary supplement use among adolescents attending secondary schools in Trinidad and Tobago.

OBJECTIVE: The objective of the present study was to determine the knowledge and practices among Trinidad and Tobago school-attending adolescents towards energy drinks (ED), alcohol combined with energy drinks (AwED), weight-altering supplements (WAS) and vitamin/mineral supplements (VMS) and their experience of adverse effects associated with such use. DESIGN: A cross-sectional, proportionate, stratified sampling strategy was adopted using a self-administered, de novo questionnaire. SETTING: Secondary schools throughout Trinidad and Tobago. SUBJECTS: Students aged 15-19 years. RESULTS: Five hundred and sixty-one students participated, an 84% response rate; 43·0% were male, 40·5% East Indian and 34·1% mixed race. VMS, ED, WAS and anabolic steroids were used by 52·4%, 44·0%, 8·9% and 1·4% of students, respectively, with 51·6% of ED users using AwED. Predictors of use of AwED were males and students who played sport for their school (OR = 1·9; 95% CI 1·2, 3·2 and OR = 2·6; 95% CI 1·4, 4·7, respectively). Predictors of ED use were males and attendees of government secondary schools (OR = 1·7; 95% CI 1·1, 2·4 and OR = 1·7; 95% CI 1·2, 2·4, respectively). Side-effects, mainly palpitations, headaches and sleep disturbances, were reported in 20·7% of dietary supplement users. CONCLUSIONS: Many adolescent students in Trinidad and Tobago use dietary supplements, including ED and AwED, and about one-fifth of users experience side-effects. Identification of students at risk for ED, AwED and WAS use and education of students about the dangers of using dietary supplements need to be instituted to prevent potential adverse events.

Premenopausal vasomotor symptoms in an ethnically diverse population.

OBJECTIVE: The prevalence of vasomotor symptoms (VMS) among women aged 45 years or older who report regular menses has not been described well. Variability by race/ethnicity is expected. METHODS: A cross-sectional analysis of Group Health enrollees was performed among women ages 45-56 y with regular and no skipped menses, and not taking hormones. Data were collected from electronic databases and mailed surveys, including a soy food questionnaire. Associations between race/ethnicity and VMS (ever/never; past 2 wk) were assessed using generalized linear models, controlling for age and body mass index. The prevalence of headache and joint pain, and VMS associations within race by soy intake were explored. RESULTS: A total of 1,513 premenopausal women with a mean age of 48.5 years responded to the survey; 75% were white. Native American women were most likely to report ever having VMS (66.7%), followed by black (61.4%), white (58.3%), Hawaiian/Pacific Islander (45.5%), mixed-ethnicity (42.1%), Vietnamese (40.0%), Filipino (38.9%, P < 0.05), Japanese (35.9%, P < 0.01), East Indian (31.3%, P < 0.05), Chinese (29.0%, P < 0.001), and other Asian (25.6%, P < 0.001) women, as compared with white women. Hispanic women were less likely to have VMS (41.7%) than non-Hispanic white women (58.8%, P < 0.001). Among white women, but not among other women, soy intake was associated with VMS (P = 0.03). CONCLUSIONS: Among a diverse population of premenopausal women, VMS prevalence is high at 55%. Asian (vs white) and Hispanic (vs non-Hispanic white) women are less likely to report ever having VMS, a pattern similar to that observed during the menopausal transition and early postmenopause in our studies. White women with more VMS seem to include more soy in their diet.

Síndrome de Bonnet-Wybur-Mason: dos polos de un espectro / The Bonnet-Wyburn-Mason syndrome: two poles of one spectrum

Se comunican los casos de dos pacientes con síndrome de Bonnet, Wyburn-Mason en quienes existía un aneurisma cirsoide de la retina de diferente grado de desarrollo. En uno, el cuadro oftalmoscópico era obvio; en tanto que en el otro la manisfestación fundamental era una tortuosidad vascular acentuada y en quien solo la angiografía fluoresceínica del fondo ocular mostró sutiles cambios compatibles con una malformación arteriovenosa localizada. Otro elemento inusual en el comportamiento de este tipo de malformaciones fue la asociación a una coartación de la aorta torácica y multiples anomalías esqueléticas sencillas, así como la obstrucción de un segmento muy desarrollado de la malformación arteriovenosa con infarto hemorrágico retiniano e involución posterior de parte de ella

We communicate the cases of two patients with syndrome of Bonnet, Wyburn-Mason who had cirsoide aneurysms of the retina of differnt degrees of development. In one, the ophthalmoscopic picture was obvious, while on the other, The primary manifestation was a marked vascular tortuosity and in which only the ocular fundus fluorescein angiography showed subtle changes consistent with a located arteriovenous malformation. Another unusual element in the behavior of this type of malformations was a coarctation of the thoracic aorta and multiple skeletal anomalies simple associated, as well as the obstruction of a highly developed portion of the retinal arteriovenous malformation with hemorrhagic infarction and consecutive involution of part of it

The cross- ethnic variations in the prevalence of headache and other somatic complaints among adolescents in Northern Israel.

BACKGROUND: Headache is the most common cause for chronic or recurrent pain in childhood and adolescence. Chronic pain may have a long-term effect on adolescents. It might contribute to functional limitations, such as poor school attendance, and it may adversely affect development of healthy social relationships. The aim of our study was to examine the cross- ethnic variation in the prevalence of headache in a non- clinical sample of adolescents in Northern Israel and to learn about its association to other somatic complaints. METHODS: A self-administered, anonymous questionnaire was presented to 2,088 tenth grade students attending 19 high-schools in Northern Israel (all the public high schools within two districts). Participants were Jews and Arabs, the latter including Muslim, Christians, and Druze, aged 15 to 16. Parental and student consent was obtained from all participants. The study was approved by the IRB of our institution. RESULTS: All 2088 questionnaires were returned although only 2019 were usable and analyzed. Arab adolescents comprised 55% (1117) of the analyzed sample and Jews 45% (902), 56% of participants were girls. Of the Arab participants, 18.6% reported having frequent headaches (girls 25.3%, boys 9.1%, P<0.0001) much less than their Jewish peers (P<0.0001) among whom 27.9% reported having frequent headaches (girls 35.6%, boys 19% P<0.0001). Other somatic complaints such as abdominal pain, palpitations, disordered sleep and fatigue were more frequent in adolescents (Jews and Arabs, girls and boys) who suffered from headaches than in their peers who did not report having headaches (P<0.0001), the same pattern observed in the Jewish and the Arab group. CONCLUSIONS: Headache is a frequent complaint among adolescents in Northern Israel. Jewish adolescents reported having headaches more frequently than their Arab peers. Those who suffered from frequent headaches also reported having significantly more other somatic complaints than adolescents without headaches. Girls had more somatic complaints then boys in the two ethnic groups.

Self-reported aural symptoms, headache and temporomandibular disorders in Japanese young adults.

BACKGROUND: To investigate the associations of aural symptoms, headache and depression with the presence of temporomandibular disorder (TMD) symptoms in a young adult population in Japan. METHODS: A personal interview survey was conducted on first-year university students (n = 1,930) regarding symptoms of TMD, aural problems, headache, shoulder pain and depression. Logistic regression was applied to assess the associations of these problems with the presence of TMD symptoms after controlling for age and gender. RESULTS: Among the 1,930 students, 543 students exhibited TMD symptoms and were classified into 7 groups: clicking only (Group I, n = 319), pain in the TMJ only (Group II, n = 21), difficulty in mouth opening only (Group III, n = 18), clicking and pain (Group IV, n = 29), clicking and difficulty in mouth opening (Group V, n = 48), difficulty in mouth opening and pain (Group VI, n = 11), and combination of three symptoms (Group VII, n = 97). The control group (n = 1,387) were subjects without any TMD symptoms. After adjusting for age and gender, a strong association was observed between TMD symptoms (Group II and IV) and tinnitus (OR = 12.1 and 13.2, respectively). TMD symptoms (Group I, II and III) were also associated with vertigo and headache. Otalgia and depression were significantly associated with the presence of clicking only. CONCLUSIONS: TMD symptoms were significantly correlated to aural symptoms and headache. A functional evaluation of the stomatognathic system should be considered in subjects with unexplained aural symptoms and headache.

Self-reported comorbid pains in severe headaches or migraines in a US national sample.

AIMS: To compare prevalence of self-reported comorbid temporomandibular joint muscle disorder-type, neck, back, and joint pains in people with severe headache or migraine; and analyze these self-reported pains in the 2000-2005 US National Health Interview Survey by gender and age for non-Hispanic whites, Hispanics, and non-Hispanic blacks (African Americans). METHODS: National Health Interview Survey data included information on gender, age, race, ethnicity, health status, and common pain types: severe headache or migraine, temporomandibular joint muscle disorder-type, neck, and low back in the last 3 months, as well as prior-month joint pains. Analyses included survey prevalence estimation and survey logistic regression to obtain odds ratios and 95% confidence intervals. RESULTS: The study included 189,967 adults: 48% males, 52% females; 73% white, 12% Hispanic, and 11% black. Of the entire sample, 29,712 (15%) reported severe headache or migraine, and 19,228 (64%) had severe headache or migraine with at least 1 comorbid pain. Two or more comorbid pains were reported in 10,200 (33%), with no gender difference, and with Hispanics (n = 1847 or 32%) and blacks (n = 1301 or 30%) less likely to report 2 or more comorbid pains than whites (n = 6747 or 34%) (odds ratio = 0.91, P = .032; OR = 0.82, P < .001, respectively). This group also reported significantly lower ratings of self-rated health (P < .001). Differences in type of comorbid pain by age patterns were found. CONCLUSIONS: Severe headache or migraine is often associated with other common pains, seldom existing alone. Two or more comorbid pains are common, similarly affecting gender and racial/ethnic groups.

Going to the USA--a US headache center from an Italian perspective.

During a period I spent at the UCSF Headache Center in the USA, I noted striking differences between the US health-care system and the Italian one in which I was trained. Here, I aim to outline some of these differences from a scientific-and, more importantly, from a sociocultural-point of view. Awareness of these aspects may help us to better understand different approaches to the diagnosis and treatment of various diseases, including headache.

Typology of chronic pain among overweight Mexican Americans.

Having a better understanding of the intersection between chronic pain and obesity in the Mexican American community can be valuable for pain management specialists in determining treatment, service, and prevention strategies. The objectives of this study were (1) to describe the type and severity of chronic pain among overweight/obese Hispanic adults aged 40 years and older, and (2) to determine the association between chronic pain indices and key demographic variables, including excessive weight. Hispanic adults (N=101) were interviewed using validated questionnaires and measured for BMI and waist circumference. Data analyses revealed that most participants had widespread pain; 60% were suffering severe pain (including back, knee, and shoulder pain); the most common pain location was head (headache, 80%), followed by knee and upper back (75-76%), shoulder (73%) and lower back (73%). Greater obesity was associated with some negative pain outcomes. Results are relevant for pain management with this at-risk population.

Giant cell arteritis: clinical features of patients visiting a headache clinic in Japan.

OBJECTIVE: The first symptom of giant cell arteritis (GCA) is usually a headache. Japan has a low prevalence of GCA, and clinical features of this disorder have not been fully investigated. We conducted a retrospective evaluation of clinical features in patients with giant cell arteritis who visited a headache clinic in Japan. METHODS: Clinical and demographic data were obtained from clinical examinations, face-to-face interviews, and hospital records. PATIENTS: Subjects comprised 19 patients (9 men, 10 women). RESULTS: Mean age at disease onset was 78.1 ± 4.8 years (range, 71-86 years). Seventeen of 19 patients (89.5%) had consulted other medical institutions before consulting our hospital, but only 2 of those patients had been diagnosed with GCA at these medical institutions. Manifestations at disease onset included headache (89.5%), ear pain (5.3%), and jaw pain (5.3%). Ocular manifestations were reported in 2 patients (10.5%). No loss of vision occurred. One patient showed trigeminal nerve palsy involving the third division of the nerve. Jaw claudication was observed in 3 patients (15.8%). Concomitant polymyalgia rheumatica was seen in 3 patients (15.8%). No patient showed upper respiratory tract symptoms, arm claudication, or aortic aneurysms. CONCLUSION: Although most patients had consulted other medical institutions before consulting our hospital, they were not diagnosed with GCA at these institutions. Infrequent clinical findings of GCA and lack of symptoms other than headache may contribute to the high rate of unrecognized and misdiagnosed cases of GCA.