Synopsis
Recognise polymyalgia rheumatica as an inflammatory pain-and-stiffness syndrome in older adults, exclude mimics and coexisting giant-cell arteritis, use a diagnostic glucocorticoid regimen with structured taper, and investigate atypical response.
- PMR causes new bilateral shoulder aching with morning stiffness longer than forty-five minutes in adults over fifty, commonly with hip-girdle pain and raised CRP or ESR.
- Confirm pain-limited movement rather than true weakness; abnormal power, CK, reflexes, sensation, rash or dysphagia requires an alternative neuromuscular assessment.
- Ask about headache, scalp tenderness, jaw claudication, visual symptoms, limb claudication and aortic pain at diagnosis and every follow-up.
Key red flags
Any visual symptom, jaw claudication or new cranial pain requires immediate GCA assessment before routine PMR review.
Headache, scalp pain, jaw claudication or any visual symptom changes treatment immediately to the GCA pathway.
Investigation priorities
Support inflammatory activity, identify anaemia or thrombocytosis and create a taper baseline.
Management branches
An adult over fifty has new bilateral girdle pain and prolonged morning stiffness.
- Document stiffness, function, systemic, cranial and visual symptoms and examine temporal arteries, pulses, joints, shoulder mechanics and true muscle power.
- Obtain inflammatory, blood, metabolic, thyroid and muscle tests and add RA, paraprotein, infection or imaging assessment from atypical features.
Symptoms improve substantially and inflammatory markers normalise or return toward baseline.
Key medicines
PrednisoloneStart 15 mg orally once daily for uncomplicated PMR; after three weeks reduce to 12.5 mg for three weeks, then 10 mg for four to six weeks, then by 1 mg every four to eight weeks if remission persists.
Methotrexate with folic acidFor repeated relapse or high steroid-toxicity risk, specialists commonly start 7.5–15 mg orally once weekly with folic acid at least 5 mg on another day and titrate by response.