Causes
The exact cause of Polymyalgia Rheumatica is unknown, but it is believed to be an autoimmune condition, meaning the body's immune system mistakenly attacks its own tissues. Factors that may play a role include:- Genetics: There appears to be a genetic predisposition, as PMR is more common in people of Northern European descent.
- Age: PMR almost exclusively affects people over the age of 50, with the average age of onset around 70.
- Environmental factors: Some research suggests that environmental triggers, such as infections, might play a role in initiating the condition in genetically susceptible individuals, but no specific trigger has been definitively identified.
Symptoms
The symptoms of Polymyalgia Rheumatica typically develop quickly, often over a few days or weeks, and can include:- Widespread pain and stiffness: This is the hallmark symptom, affecting both sides of the body, most commonly in the shoulders, neck, upper arms, hips, and thighs.
- Morning stiffness: Stiffness is usually most severe in the morning and can last for 30 minutes or longer. It can also worsen after periods of inactivity.
- Fatigue: Significant tiredness and lack of energy are common.
- Mild fever: Some individuals may experience a low-grade fever.
- Loss of appetite and unintentional weight loss.
- General feeling of being unwell (malaise).
- Reduced range of motion: Difficulty with everyday tasks such as raising arms above the head, getting out of bed, or standing up from a chair.
Diagnosis
Diagnosing Polymyalgia Rheumatica involves a combination of:- Medical history and physical examination: The doctor will ask about your symptoms, their onset, and conduct a physical exam to check for tenderness and limited range of motion.
- Blood tests:
- Erythrocyte Sedimentation Rate (ESR): This test measures how quickly red blood cells settle at the bottom of a test tube. A high ESR indicates inflammation in the body.
- C-reactive protein (CRP): Another marker of inflammation. High levels of CRP are common in PMR.
- Other blood tests may be done to rule out other conditions that can cause similar symptoms, such as rheumatoid arthritis, lupus, or thyroid problems.
- Imaging tests: Imaging tests like X-rays, MRI, or ultrasound are generally not used to diagnose PMR but may be done to rule out other causes of pain.
Treatment
Polymyalgia Rheumatica typically responds well to treatment, primarily with corticosteroids. The goal of treatment is to relieve symptoms and prevent recurrence.- Corticosteroids:
- Low-dose oral corticosteroids (e.g., prednisone) are the most effective and common treatment. Symptoms often improve dramatically within a few days of starting treatment.
- The dose is gradually tapered over time, usually over several months to a few years, to the lowest effective dose to minimize side effects.
- Pain relievers: Over-the-counter pain relievers like ibuprofen or naproxen may be used for mild pain, but corticosteroids are usually more effective for the inflammatory pain of PMR.
- Calcium and Vitamin D supplements: Often prescribed with corticosteroids to help prevent bone loss (osteoporosis), a common side effect of long-term steroid use.
- Bone-preserving medications: Bisphosphonates may also be prescribed to protect bone density, especially with prolonged corticosteroid use.
- Physical therapy: May be recommended to help maintain muscle strength and flexibility, especially during periods of reduced activity due to pain.
- Monitoring: Regular follow-up with your doctor is essential to monitor symptoms, adjust medication dosage, and watch for potential side effects of corticosteroids or the development of Giant Cell Arteritis.
Living With Polymyalgia Rheumatica
Polymyalgia rheumatica responds to prednisone so reliably that the first days of treatment often feel like a cure. The difficulty is everything after: a taper that lasts one to two years, flares along the way, the side effects of a steroid taken for that long, and a related artery condition that can threaten sight.
The response to prednisone is itself a test
Near-complete relief within about a week of a low dose confirms the diagnosis as much as any blood test. A partial response, or a need for higher doses, means something else is going on: late-onset rheumatoid arthritis, hypothyroidism, muscle pain from a statin, fibromyalgia, an infection, or occasionally a cancer, and the workup is reopened rather than the dose pushed higher.
Tapering without stalling
The dose is reduced in small steps every few weeks, guided by symptoms rather than by the sedimentation rate alone, which can drift up without a flare. Stiffness returning during a step down is treated by going back to the last dose that worked, holding, and trying again more slowly; it is not a failure. Never stop prednisone abruptly after months of use, because the adrenal glands need time to resume their own production and adrenal insufficiency can follow. Carry a note that you take prednisone and tell any surgeon or emergency physician, for the same reason. Relapse during tapering is common, and many people need a longer course than first expected.
Protecting bones, sugar, eyes, and sleep
A bone density scan at the start and a bisphosphonate such as alendronate for those at risk, with calcium and vitamin D, prevent the osteoporosis that months of steroid cause; our bone health after 50 guide covers the details. Blood sugar and blood pressure are checked, since prednisone raises both and can unmask diabetes. Taking the dose in the morning limits insomnia. Cataracts and glaucoma are more likely, so an eye exam is scheduled. The shingles vaccine is worth completing early in the course.
When steroids alone are not enough
Repeated flares, a taper that stalls above a low dose, or side effects that cannot be tolerated are reasons to add a steroid-sparing medication. Methotrexate is the traditional choice, and sarilumab, an interleukin-6 blocker, is now approved specifically for polymyalgia that relapses during tapering. Both are started with a rheumatologist, and our musculoskeletal team coordinates monitoring between visits.
The artery condition that changes everything
A new headache, tenderness of the scalp or temple, pain in the jaw when chewing, or any change in vision, at diagnosis or at any point during treatment, means possible giant cell arteritis, which needs a much higher steroid dose the same day to prevent permanent blindness, often followed by tocilizumab. Our polymyalgia and temporal arteritis article explains how the two conditions are linked. NIAMS and the American College of Rheumatology publish patient guidance on treatment and tapering.
If your prednisone taper keeps stalling, or you have a new headache or jaw pain while being treated, schedule a visit; a new change in vision is an emergency.