Patient information from BMJ

Polymyalgia rheumatica

Last published:Apr 19, 2022

Polymyalgia rheumatica (PMR for short) mainly affects the muscles in the neck, shoulders, and hips. The main symptoms are pain and stiffness in these areas first thing in the morning.

There are medicines that can relieve the symptoms and often clear them up completely. But this can take time and you might need treatment more than once.

You can use our information to talk to your doctor about the best treatments for you.

What is polymyalgia rheumatica?

Polymyalgia rheumatica (PMR) is a condition that causes inflammation (swelling) in the muscles around the shoulders, neck, and hips.

This swelling causes pain and extreme stiffness, mainly first thing in the morning. This stiffness usually lasts for at least 45 minutes. Many people find it hard to move much, if at all, until the stiffness passes.

PMR is not especially common: it affects about 6 in every 10,000 people over the age of 50. It hardly ever affects people younger than this.

It’s not clear what causes PMR. It has been suggested that it could be linked to an infection, or that it could be genetic. But no one really knows.

What we do know is that you are more likely to have PMR if you are:

• over 50 years old. Most people diagnosed with PMR are actually over 70

• of white, northern European ancestry

• a woman - about two-thirds of people diagnosed with PMR are women.

What are the symptoms?

The main symptoms of PMR are pain and stiffness that mainly affects the neck, shoulders, and hips. This is at its worst first thing in the morning, but it usually improves as the day goes on.

Some people find that their symptoms are so bad in the morning that getting out of bed is difficult, or that they might have to wait a while before they can get up.

Other symptoms

PMR can cause other problems in some people. These can include:

• a mild fever (called a low-grade fever)

• weight loss and loss of appetite

• feeling physically weak and generally unwell

• night sweats

• pain in the wrists and hands, and

• swelling of the hands and feet.

Some people with PMR develop depression because of their symptoms. If this happens to you, talk to your doctor.

Depression is not uncommon with conditions that cause pain and discomfort. Your doctor will know this, and should be able to prescribe treatments that help.

Diagnosing PMR

The main ways that doctors diagnose PMR are to examine you and to ask you about your symptoms.

The symptoms of PMR are often similar to those of conditions such as rheumatoid arthritis and bursitis (a type of shoulder injury). So it can take time to diagnose PMR accurately. Your doctor may ask you quite a lot of detailed questions.

For example, they will probably ask you things like:

• where exactly your pain and stiffness happen

• when these symptoms happen and how long they last, and

• whether your symptoms improve as the day goes on, and how much they improve.

Your doctor might also ask you to move your arms, shoulders, and legs, to see if and how your movement is affected by your symptoms.

• people are more likely to have PMR if they also have a condition called giant cell arteritis, which causes swelling of the lining of the arteries. So your doctor should check for signs of this condition

• your doctor might suggest that you try a short course of corticosteroid tablets. If your symptoms improve within a few days, this suggests that they are caused by PMR and not by something else.

Tests such as scans and blood tests can also be useful, mainly in finding or ruling out other causes of pain and stiffness.

What treatments are available?

The main treatment for PMR is corticosteroid tablets. These drugs are powerful anti-inflammatories. This means that they reduce inflammation (swelling) that can cause pain and stiffness.

Corticosteroids can make a big difference to many people’s symptoms. But they can also cause harmful side effects.

Most of these side effects only happen when someone has been taking corticosteroids for more than a short time. But some of them can be serious. So your doctor will want to give you the lowest dose that helps you, for the shortest possible time.

Side effects of corticosteroids can include:

• mood changes and other mental-health symptoms. Unlike some side effects, this can happen in the short term. So it’s good to be aware that this can happen

• developing type 2 diabetes

• increased appetite, which can lead to weight gain

• feeling tired

• being more likely to get infections

• indigestion or bleeding from the stomach,

• raised blood pressure, and

• weakened bones. If you are going to take corticosteroids for more than a short time your doctor should prescribe a vitamin D supplement to help keep your bones strong. It’s important to get enough calcium too. Your doctor might recommend an extra medicine, called a bisphosphonate, to protect your bones.

If your symptoms improve or clear up with corticosteroids, your doctor will probably suggest that you either take a lower dose, or stop taking them completely, at least for a while. This helps to prevent side effects.

If you find that your symptoms start to return, your doctor will probably suggest that you take corticosteroids again, at the lowest and safest possible dose, until your symptoms improve or go.

Most people need several courses of treatment, sometimes over two or three years, to get rid of their symptoms completely.

Some people have withdrawal symptoms when they stop taking corticosteroids.

Some of these withdrawal symptoms, such as aches and tiredness, are quite similar to the symptoms of PMR. So it can be quite hard to know what’s causing them.

Because of this, and the need to prevent side effects, your doctor will want to keep an eye on you, both while you are taking steroids, and when you stop.

Other medicines

Some people find that corticosteroids don’t help them enough, or that their symptoms clear up but then come back just as bad as before.

If this happens to you, your doctor might suggest medicines that are usually used to treat other conditions that cause inflammation, such as rheumatoid arthritis.

These medicines help to stop your immune system from attacking your tissues and joints. This can help to reduce the inflammation that causes PMR.

Like corticosteroids, these medicines cause side effects in some people. So your doctor should discuss these with you, and follow up with you regularly if you need to take them.

NSAIDs

You’ve probably heard of anti-inflammatory drugs such as ibuprofen. The medical name of this type of medicine is non-steroidal anti-inflammatory drugs (NSAIDs).

Most of the time NSAIDs are not recommended for treating PMR.

Your doctor may suggest them for a short time if you are stopping corticosteroids. But they can cause side effects if taken for too long, including bleeding in the stomach.

If your doctor thinks that you need to take them for longer, they might prescribe something to help protect your stomach.

What to expect in the future

With treatment, the outlook for most people with PMR is good. Symptoms usually clear up completely or improve greatly.But recovery doesn’t usually happen quickly. Most people need to take several courses of treatment - usually corticosteroids - over two to three years.And some people need treatment for longer, and with different drugs.Most doctors recommend regular follow-up for people being treated for PMR, usually every one to thtee months. This helps your doctor to:

• check how you are improving

• keep an eye on side effects, and

• increase or reduce your medicine dose as needed.

You should also tell your doctor right away if your symptoms change suddenly or if you get new symptoms.