Polymyalgia rheumatica (PMR)

The pain is quite different from the ache you may feel after unusual exercise. It is often widespread and is made worse by movement but may also wake you at night.

It's also common to feel unwell or to have a slight fever, and you may well lose weight. People with polymyalgia rheumatica often feel low and may even become depressed.

Polymyalgia is sometimes associated with painful inflammation of the arteries of the skull. This is called temporal arteritis or giant cell arteritis and needs prompt treatment as there is a risk of damage to the arteries of the eye.

The symptoms of temporal arteritis are:

• severe headaches and pain in the muscles of the head
• tenderness at the temples
• pain in the side of the face when chewing
• pain or swelling in the scalp
• blurred or double vision. 

About 20% of polymyalgia rheumatica patients also develop temporal arteritis, while 40–60% of patients with temporal arteritis have symptoms of polymyalgia rheumatica.

 There are three tests that may be used:

• erythrocyte sedimentation rate (ESR)
• plasma viscosity (PV)
• C-reactive protein (CRP).

The presence of inflammation alone cannot confirm the diagnosis of polymyalgia rheumatica as inflammation is a feature of many other conditions.

Anaemia (a lack of red blood cells) is quite common in polymyalgia rheumatica so your doctor may also test for this though it can also be a symptom of other conditions.

If your doctor suspects temporal arteritis, a biopsy of a small piece of artery may be taken from the scalp and examined under a microscope.

Normally polymyalgia rheumatica will be diagnosed and treated by your GP. However, you may be referred to a rheumatologist if there is any doubt about the diagnosis, or if there are complicating factors.

Polymyalgia rheumatica drugs

Standard painkillers or anti-inflammatory drugs on their own are not enough to ease the pain. However, corticosteroid treatment is usually very effective.

Steroids do not cure polymyalgia rheumatica but have a powerful effect in reducing inflammation. Symptoms often improve significantly within a day or two, though treatment usually needs to continue for two years or more to prevent relapses.

The steroid tablet most often prescribed is prednisolone. In most cases a dose of 15 mg of prednisolone a day makes the symptoms disappear completely. However, if you have temporal arteritis, you will need higher doses in order to prevent eye damage.

After a time your doctor will try to reduce the dose of steroids to avoid potential side-effects – such as osteoporosis. The reduction will be made in stages depending on your symptoms and sometimes repeat ESR test results. If symptoms return when the dose is reduced your doctor may have to increase the dose slightly for a short time, and then try again to reduce it after several weeks.

Occasionally other drugs called immunosuppressants are used to help keep the disease under control while reducing the dose of steroids. Immunosuppressants are usually given only to people who have had repeated relapses.

Even when you feel well, your doctor may wish to see you regularly so that you can be assessed for signs of a relapse or side-effects from the drugs. Your doctor may want to check your general health and you may also be asked to have a bone density (DEXA) scan to assess the strength of your bones.

If your symptoms are mild, you may be advised to take analgesics such as paracetamol to help ease the pain and stiffness, along with small doses of steroid tablets. Alternatively, your doctor may recommend anti-inflammatory drugs alongside low-dose steroids.

Your doctor may decide that you should continue on a small dose (a maintenance dose) of steroid tablets indefinitely. You should not stop taking your steroid tablets or alter the dose unless advised by your doctor.

If you need long-term steroid treatment your doctor may advise drugs to help guard against osteoporosis, for example, bisphosphonates such as risedronate or alendronate.

Exercise

You'll need to find the right balance between rest and activity. Too much exercise is likely to make your symptoms worse. However, activity usually helps to ease morning stiffness.

Weight-bearing exercise (any exercise that involves walking or running) is best for maintaining bone strength and guarding against osteoporosis, but walking is usually most suitable for people with polymyalgia rheumatica.

Diet and nutrition

Steroid treatments reduce the amount of calcium absorbed from the gut and increase calcium loss through the kidneys. To counteract this we recommend a daily intake of calcium of 1,000 milligrams (mg) or 1,500 mg if you are over 60.

A pint of milk a day, together with a reasonable amount of other foods that contain calcium, should be sufficient.

Vitamin D is needed for the body to absorb calcium. Vitamin D is obtained from some foods, especially oily fish, and is converted into the active form when sunlight falls on the skin. It is sometimes necessary to take a supplement containing 10–20 micrograms (µg) of vitamin D, especially for people over 60.

What else should I know about polymyalgia rheumatica?

• We recommend you carry a steroid card that shows what dose you are on and how long you have been taking them. If you need to see another doctor, for example while you are away from home, show them the card – depending on what treatment you need, the steroid dose may need to be adjusted.
• Avoid smoking and drinking excessive amounts of alcohol as both increase the risk of osteoporosis.
• Simple measures like a hot bath or shower can help to ease pain and stiffness, either first thing in the morning or after exercise.
• Sitting for any length of time may cause stiffness, making driving, for instance, more difficult. Stop from time to time on a long journey to stretch your legs.