A 22 year old woman presents with multiple episodes of right sided periorbital and temporal headache, in association with lacrimation, rhinorrhea, nausea, and vomiting. The episodes occurred up to 5 times a day, and lasted around an hour each. These attacks first started 2 years ago. All investigations, including a MRI brain, were normal. She was unresponsive to treatments for cluster headache and migraine. She is a frequent visitor to the outpatient department. Her records reveal suspicions of her using artificial tears to simulate tearing, and the fact that actual vomiting was not witnessed by any medical personnel.
The CT Angiogram of the brain appears completely normal
Appearance: clear Cell count: 2 cells/mm3 (<5 cells/mm3) Protein: 25 mg/dl (15-40 mg/dL) Glucose: 58 mg/dL (½ to ⅔ of blood glucose) Random Blood Sugar: 97 mg/dL
You wonder if a temporal artery biopsy is really indicated.
Beck Depression Inventory (BDI) score: 11/63