Polymyalgia Rheumatica: Symptoms, Types, Causes and Treatment

Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disorder that most commonly affects older adults. Despite its prevalence, PMR is often misunderstood or mistaken for other musculoskeletal conditions, leading to delays in diagnosis and management. In this article, we’ll explore the clinical features, subtypes, underlying causes, and modern treatment approaches for PMR—drawing from the latest research to provide a clear, patient-centered guide.

Symptoms of Polymyalgia Rheumatica

The experience of PMR can be life-altering, especially at its onset. The disease typically strikes people over 50 and is characterized by a sudden onset of pain and stiffness, most prominently in the shoulders, neck, and hips. These symptoms can dramatically impact daily function, particularly in the morning.

Symptom	Location	Clinical Feature	Source
Aching/Pain	Shoulders, hips	Sudden, bilateral discomfort	1 3 4 5 7
Morning Stiffness	Neck, shoulders, hips	Lasts ≥45 minutes	1 3 4 5 7
Limited Movement	Shoulders, hips	Difficulty with daily activities	2 3 4 5
Systemic Signs	General	Fatigue, low-grade fever	2 3 5 7
Elevated Markers	Blood	High ESR/CRP	1 2 3 4 5 7

Table 1: Key Symptoms

Overview of Symptoms

PMR’s signature is a combination of pain and stiffness that appears quickly and is most severe after periods of inactivity, such as waking in the morning. The discomfort is typically symmetrical, affecting both sides of the body equally 1 3 4 5 7.

Morning Stiffness and Pain

• Morning stiffness: Most patients experience stiffness lasting 45 minutes or more upon waking 1 3 4 5.
• Aching: The pain is deep, often centered in the shoulders and hips, and sometimes extends to the neck and thighs 3 4 5 7.
• Movement: Daily tasks—like getting dressed or rising from a chair—become challenging due to pain and restricted motion 2 4.

Systemic and Laboratory Findings

• Fatigue and malaise: Many patients feel unusually tired or unwell 5 7.
• Low-grade fever and weight loss: Less common, but may be present in a subset of patients 3 5.
• Inflammatory markers: Blood tests nearly always show elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) 1 2 3 4 5 7.

Related and Overlapping Symptoms

Some patients may experience symptoms overlapping with those of giant cell arteritis, such as headaches or visual disturbances, especially if both conditions occur together 1 2 3 5. However, muscle weakness and wasting are not typical of PMR and suggest alternative diagnoses 2.

Types of Polymyalgia Rheumatica

PMR is not a uniform disease; rather, it can manifest in different forms or in association with other conditions. Understanding these types helps tailor diagnosis and management.

Type	Distinguishing Feature	Association/Trigger	Source
Isolated PMR	Classic pain/stiffness, no arteritis	None or unknown	3 4 5 7
PMR with GCA	PMR plus vascular symptoms	Giant cell arteritis (GCA)	1 2 3 4 5
Triggered PMR	Onset after infection/vaccination	Environmental trigger	9

Table 2: Forms of PMR

Isolated PMR

• Definition: Patients present solely with PMR symptoms—pain and stiffness—without evidence of vascular inflammation or giant cell arteritis 3 4 5.
• Course: Most cases run a benign course, responding well to steroids 2 4 5.

PMR Associated with Giant Cell Arteritis (GCA)

• Definition: In some patients, PMR occurs together with GCA, a primary vasculitis affecting large arteries, most notably the temporal arteries 1 2 3 4 5 7.
• Symptoms of GCA: Headache, scalp tenderness, jaw claudication, visual disturbances. These symptoms require urgent attention due to risk of vision loss 1 2 3 5.
• Overlap: Up to half of GCA patients may have PMR symptoms, and about 10-20% of PMR patients develop GCA 3 4 5.

PMR Triggered by Environmental Factors

• Recent findings: A subset of patients report PMR onset after infections or vaccinations (e.g., influenza), suggesting an environmentally triggered form 9.
• Clinical course: These patients may have higher inflammatory markers at onset but often respond rapidly to therapy 9.

Other Considerations

• Mimics: Other autoimmune, infectious, or neoplastic diseases can resemble PMR and must be ruled out for accurate diagnosis 4 5.
• Imaging phenotypes: Modern imaging reveals that bursitis is common in PMR, and PET scans may show vascular uptake in those with associated vasculitis 4 7.

Causes of Polymyalgia Rheumatica

The exact cause of PMR remains elusive, but research points to a complex interplay of genetic, immunological, and environmental factors. Understanding what underlies PMR can help patients appreciate why it manifests and how it might be managed.

Factor	Evidence/Description	Role in PMR	Source
Age	Occurs >50 years	Age-related immune changes	3 5 6 8
Genetics	Possible predisposition	Familial clustering observed	6 8
Immune Dysregulation	Innate/adaptive imbalance	Inflammatory cascade	6 8
Environmental Triggers	Infection/vaccination	Trigger in susceptible hosts	8 9

Table 3: Suspected Causes

Age and Genetic Susceptibility

• Age: PMR almost exclusively affects those over 50, pointing toward changes in immune regulation with aging (immunosenescence) 3 5 6 8.
• Genetics: Family history and genetic studies suggest a heritable component, though no single gene has been identified 6 8.

Immune System Disturbances

• Innate immunity: There is evidence of hyperactive neutrophils and monocytes, with increased pro-inflammatory cytokines, especially interleukin-6 6 8.
• Adaptive immunity: Aberrant T cell (Th1/Th17) and B cell responses have been documented, but classic autoantibodies are generally not present or are non-specific 6 8.
• Mixed mechanism: PMR straddles the line between autoinflammatory and autoimmune disease, with both immune arms implicated 6 8.

Environmental Triggers

• Infections: Various studies have investigated viral and bacterial infections as initiators, but results remain inconclusive 8 9.
• Vaccinations: Some patients develop PMR following vaccinations (e.g., influenza), possibly due to an overzealous immune response in a genetically and immunologically primed host 9.
• Role of triggers: Environmental exposures may act as catalysts rather than primary causes, provoking PMR in predisposed individuals 8 9.

Pathophysiological Highlights

• Inflammation focus: The inflammatory process is centered in the synovium and periarticular structures, leading to pain and stiffness without destructive joint damage 1 2 3 4 6.
• Endocrine factors: Hormonal changes with age may also contribute, though their exact role is unclear 6 8.

Treatment of Polymyalgia Rheumatica

PMR is notable for its dramatic response to glucocorticoids, but long-term management can be challenging due to relapses and steroid side effects. Treatment must be personalized, balancing symptom control with minimizing drug-related risks.

Therapy	Typical Dose/Approach	Key Role/Outcome	Source
Glucocorticoids	Prednisone 12.5–25 mg/day	Rapid symptom relief	1 3 4 5 7 10 12
Tapering Regimen	Slow reduction (<1 mg/mo)	Prevents relapses	10 11 12
Methotrexate	10 mg/week or more	Steroid-sparing agent	4 7 10 11
Biologics	Tocilizumab (select cases)	For refractory/relapsing PMR	4 13

Table 4: Main Treatments

Glucocorticoids: The Cornerstone

• Initial therapy: Low-to-moderate dose prednisone (12.5–25 mg daily) is usually started, leading to rapid resolution of pain and stiffness in most patients 1 3 4 5 7 10 12.
• Response: Most patients improve within days; lack of response should prompt reconsideration of the diagnosis 1 4 5 12.
• Duration: Treatment is often needed for 6–24 months, with gradual tapering 5 7 10.

Tapering and Relapse Management

• Tapering strategy: Slow dose reductions (typically <1 mg/month once below 10 mg/day) are associated with fewer relapses and better outcomes 10 11 12.
• Relapses: Common during tapering; may require temporary dose increases 4 5 10 11.

Steroid-Sparing Agents

• Methotrexate: Can be added in patients with frequent relapses or high risk for steroid side effects. Doses of 10 mg/week or higher are effective 4 7 10 11.
• Other DMARDs: Most have limited evidence; anti-TNF agents (e.g., infliximab) are ineffective 11.

Biologics

• Tocilizumab: An anti-interleukin-6 receptor antibody, has shown promise in steroid-refractory PMR and in reducing steroid exposure, but is not yet standard first-line therapy 4 13.

Managing Associated Giant Cell Arteritis

• Higher steroid doses: If GCA is present (e.g., vision symptoms), high-dose prednisone (e.g., 50 mg/day) is used to prevent vision loss 1.
• Urgency: Immediate treatment is critical if GCA symptoms are suspected 1 3 5.

Non-Pharmacological Measures and Monitoring

• Physical therapy: Helps maintain mobility and function, though evidence is limited 12.
• Monitoring: Regular follow-up is needed to assess symptom control, side effects, and monitor for complications 12.

Prognosis

• Mortality: Not increased in patients with isolated PMR 4.
• Long-term outlook: Most patients can eventually discontinue treatment, but some may need long-term therapy for relapses 5 10 11.

Conclusion

Polymyalgia rheumatica is a common yet complex inflammatory disease predominantly affecting older adults. Recognizing its symptoms, understanding its diverse forms, appreciating the underlying causes, and implementing evidence-based treatment are all critical steps toward optimal patient care.

Key Takeaways:

• PMR presents with sudden, symmetrical pain and stiffness in the shoulders, hips, and neck, mainly in people over 50 1 3 4 5 7.
• The disease can occur alone, with giant cell arteritis, or be triggered by infections/vaccinations 1 3 4 5 7 9.
• Its cause is multifactorial, involving genetic predisposition, immune dysregulation, and environmental triggers 6 8 9.
• Glucocorticoids remain the mainstay of treatment; slow tapering and adjunct therapies like methotrexate or tocilizumab may be required for relapsing or severe cases 1 4 7 10 11 12 13.
• Most patients have a good prognosis, but careful monitoring and individualized care are essential for long-term well-being.

With growing scientific insight and collaborative care, the outlook for those living with PMR continues to improve.