brand logo

Am Fam Physician. 2022;106(4):420-426

Patient information: See related handout on polymyalgia rheumatica and giant cell arteritis.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Polymyalgia rheumatica and giant cell arteritis are inflammatory conditions that occur predominantly in people 50 years and older, with peak incidence at 70 to 75 years of age. Polymyalgia rheumatica is more common and typically presents with constitutional symptoms, proximal muscle pain, and elevated inflammatory markers. Diagnosis of polymyalgia rheumatica is clinical, consisting of at least two weeks of proximal muscle pain, constitutional symptoms, and elevated erythrocyte sedimentation rate or C-reactive protein. Treatment of polymyalgia rheumatica includes moderate-dose glucocorticoids with a prolonged taper. Giant cell arteritis, also known as temporal arteritis, usually presents with new-onset headache, visual disturbances or changes, constitutional symptoms, scalp tenderness, and temporal artery symptoms. Inflammatory markers are markedly elevated. Temporal arterial biopsy should be used for diagnosis. However, color duplex ultrasonography, magnetic resonance imaging, and fluorodeoxyglucose positron emission tomography may be helpful when biopsy is negative or unavailable. All patients with suspected giant cell arteritis should receive empiric high-dose glucocorticoids because the condition may lead to blindness if untreated. Tocilizumab is approved by the U.S. Food and Drug Administration for giant cell arteritis and should be considered in addition to glucocorticoids for initial therapy. Polymyalgia rheumatica and giant cell arteritis respond quickly to appropriate dosing of glucocorticoids but typically require prolonged treatment and have high rates of relapse; therefore, monitoring for glucocorticoid-related adverse effects and symptoms of relapse is necessary. Methotrexate may be considered as an adjunct to glucocorticoids in patients with polymyalgia rheumatica or giant cell arteritis who are at high risk of relapse.

Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are related inflammatory conditions, which typically affect people 50 years and older. This article provides a summary and review of the best available patient-oriented evidence for each condition.

Clinical recommendation Evidence rating Comments
Patients with PMR should be treated with the minimum effective dose of oral glucocorticoids with individualized duration.14,19,22 C Expert opinion
Early addition of methotrexate to glucocorticoid therapy should be considered in patients with PMR who are at high risk of relapse or glucocorticoid-related adverse events.7,8,19 A Consistent results from multiple randomized controlled trials
Intramuscular methylprednisolone every three weeks should be considered as an alternative to oral glucocorticoids in patients at high risk of adverse effects from glucocorticoids.8,19 B A single small, high-quality randomized controlled trial
Dose-tapering schedules for patients with PMR should be individualized based on monitoring of disease activity, laboratory markers, and adverse events.19 C Expert opinion in the absence of clinical trials
In patients with newly diagnosed GCA, noninvasive vascular imaging (i.e., magnetic resonance imaging or computed tomography angiography) of the neck, chest, abdomen, and pelvis should be performed to evaluate for large vessel involvement.20 C Lower-quality evidence and consensus guidelines
To improve chances of successful remission, patients with newly diagnosed GCA should be treated with high-dose oral glucocorticoids and subcutaneous interleukin-6 antagonist tocilizumab (Actemra) over glucocorticoids alone.8,20,38,39 A Two high-quality randomized controlled trials with consistent results and consensus guidelines
Long-term monitoring is recommended for patients with GCA who are in clinical remission.20 C Evidence showing that monitoring is low risk and there is potential for harm from not monitoring; consensus guidelines


  • Incidences of PMR and GCA vary among people 50 years and older depending on geographic location. The incidence per 100,000 people 50 years and older ranges from 2 (Korea) to 113 (Norway) for PMR and 1 (Turkey) to 44 (Iceland) for GCA.1

  • Approximately 20% of patients with PMR have GCA, and about 50% of patients with GCA have PMR.2,3

  • Risk factors for PMR and GCA include female sex, Northern European ancestry, and age.46

  • The age of onset for both conditions is typically 50 years and older, with peak incidence at 70 to 75 years of age.2,3

Polymyalgia Rheumatica


  • With no definitive diagnostic test for PMR, the diagnosis is clinical. The typical clinical presentation is shown in Table 1.3,710

  • The differential diagnosis of PMR is summarized in Table 2.7,9,11,12

Patient demographics
Age 50 years and older
Acute onset of bilateral pain in the shoulder or pelvic girdle
Associated morning stiffness lasting longer than 45 minutes
Constitutional symptoms such as fever, fatigue, night sweats, or weight loss (present in up to 50% of patients)
Physical examination
Decreased active and passive range of motion in the affected joints
Laboratory findings
Evidence of acute phase reaction (e.g., elevated inflammatory markers)
Ultrasound findings
Subdeltoid bursitis, biceps tenosynovitis, or glenohumeral synovitis
Duration of symptoms
Rapid onset of symptoms lasting longer than two weeks
Response to treatment
Rapid response to appropriate glucocorticoid therapy (typically within two to four weeks)
Polymyalgia rheumaticaGiant cell arteritis
Adhesive capsulitis
Calcium pyrophosphate deposition disease
Rotator cuff pathology
Subacromial bursitis
Dental pain/conditions
Temporomandibular disorders
Rheumatoid arthritis
Systemic lupus erythematosus
Optic neuritis
Polyarteritis nodosa
Small/medium vessel vasculitis
Parkinson diseaseCerebrovascular accident/retinal artery occlusion
Trigeminal neuralgia
Hepatitis B or C
Parvovirus B19
Acute otitis media/externa
Herpes zoster
Lung cancer paraneoplastic syndrome
Multiple myeloma
Prostate cancer
Central mass effect
Multiple myeloma
Thyroid disorders
Statin-induced myopathyDrug-induced vasculitis

History and Physical Examination

  • The patient history reveals predominantly symmetrical shoulder and thigh stiffness, which may cause difficulties in rising from a seated position and raising arms overhead.3

  • Up to 50% of patients report constitutional symptoms such as fever, fatigue, night sweats, or weight loss.3

  • Physical examination may show restricted active range of motion and weakness or tenderness in the hip and shoulder muscles.

Laboratory Studies

  • An erythrocyte sedimentation rate (ESR) of more than 30 to 40 mm per hour or elevated C-reactive protein (CRP) levels are present in approximately 90% of patients with PMR.13,14

  • Complete blood count often shows associated normochromic anemia and thrombocytosis.4 Liver function tests may show mildly elevated alkaline phosphatase.15

  • Muscle enzyme levels, including creatinine kinase, are normal in patients with PMR.16

  • Positive antinuclear antibodies, antineutrophil cytoplasmic antibodies, rheumatoid factor, and anti-citrullinated peptide antibodies are not found in patients with PMR and indicate an alternative diagnosis if present.7


  • Ultrasonography of the shoulder shows subdeltoid bursitis in up to 79% of patients with PMR and may be considered as an adjunct diagnostic study.17,18

  • If clinically indicated, chest radiography may be considered because lung cancer paraneoplastic syndrome can mimic PMR.14 An exhaustive evaluation for underlying occult malignancy or infection is not recommended.4

  • Plain radiography of the involved joints may show concomitant degenerative joint disease but does not add diagnostic value.7


  • Table 3 includes consensus treatment recommendations for PMR.7,8,1921

Already a member/subscriber?  Log In


From $145
  • Immediate, unlimited access to all AFP content
  • More than 130 CME credits/year
  • AAFP app access
  • Print delivery available

Issue Access

  • Immediate, unlimited access to this issue's content
  • CME credits
  • AAFP app access
  • Print delivery available

Article Only

  • Immediate, unlimited access to just this article
  • CME credits
  • AAFP app access
  • Print delivery available
Purchase Access:  Learn More

Continue Reading

More in AFP

More in Pubmed

Copyright © 2022 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.