Patents with polymyalgia rheumatica generally present with pain and morning stiffness in the shoulder or hip. Patients may have difficulty getting up from a chair, turning over in bed, or raising their arms. Patients are usually in good health prior to the onset of the disease. The presentation is abrupt in 50% of patients [3].

Usually affected joints include those of [2] [3] [4]:

• Shoulders
• Hips
• Knees
• Metacarpal phalangeal joints
• Wrists

The shoulders are the most common site, occurring in 70%–95% of patients. Hip and neck pain occurs in 50%–70% of patients [2] [6].

Systemic findings [10]:

• Low-grade fever
• Weight loss
• Malaise
• Fatigue
• Difficulty completing activities of daily living

The symptoms of polymyalgia rheumatica are often vague and may occur in many other disorders [3] [4] [6].

Diagnostic criteria for polymyalgia rheumatica are [10] [11]:

• Age 50 years or older
• Erythrocyte sedimentation rate ≥40 mm/h
• Pain lasting longer than 1 month and involving at least 2 sites 
• Exclusion of other diseases with similar symptoms 
• Morning stiffness lasting more than 1 hour
• Rapid response to corticosteroids

Some patients exhibit a chronic-relapsing course and may need low doses of corticosteroids for many years [4].

• Pain

  Along with the pain and stiffness of larger muscles, headache may add to the discomfort. The scalp is often tender. Pain is usually worse at night. There may be fever and weight loss before the full disease appears. [medical-dictionary.thefreedictionary.com]

  It is easy to dismiss pain in the geriatric population because both the patient and the clinician often feel pain is a normal part of aging. [clinicaladvisor.com]

  Hip and neck pain occurs in 50%–70% of patients. [symptoma.com]

  The cardinal symptoms of PMR are Muscle stiffness and spasms or cramps Muscle or joint pain The pain may be so intense that it may hamper sleep. [medindia.net]

  […] can help narrow down the cause of the pain. [en.wikipedia.org]

• Fever

  There may be fever and weight loss before the full disease appears. Patients complain that stiffness is worse in the morning and returns if they have been inactive for any period of time, a condition called gelling. [medical-dictionary.thefreedictionary.com]

  Scalp tenderness, fatigue, fevers and a general sense of illness occurs in about 50% of patients. Jaw or facial soreness, especially with chewing, also occurs in about 50% of patients. [my.clevelandclinic.org]

  The situation may be urgent if you have fever, visual problems or headache. These symptoms suggest that you could have giant cell arteritis. Prognosis Treatment may be required for years. [drugs.com]

• Weight Loss

  […] of motion in the shoulder or pelvic region, anemia, fever, weight loss, and malaise. [medical-dictionary.thefreedictionary.com]

  In addition to stiffness, you may have a fever, weakness, and weight loss. Polymyalgia rheumatica usually goes away within one year, but it could last several years. [niams.nih.gov]

  The patient may also exhibit the following symptoms: Severe weakness, fatigue, and exhaustion Mild fever with an irregular pattern Loss of appetite Anxiety and depression Unexplained weight loss Mild anemia A general feeling of being unwell or malaise [medindia.net]

• Fatigue

  Scalp tenderness, fatigue, fevers and a general sense of illness occurs in about 50% of patients. Jaw or facial soreness, especially with chewing, also occurs in about 50% of patients. [my.clevelandclinic.org]

  The symptoms are usually bilateral and symmetric, and there may also be complaints of fatigue, weight loss, depression, and fever. Another common feature of PMR is inflammation of the synovial cavities and bursae in the shoulders. [clinicaladvisor.com]

  PMR also might show systemic symptoms including low fever, weight loss, weakness, fatigue and depression. [massagetoday.com]

• Anemia

  A mild anemia is often is often present. One blood test, called an erythrocyte sedimentation rate, is very high, much more so than in most other diseases. [medical-dictionary.thefreedictionary.com]

  Hemolytic anemia with reduction of haptoglobin and cold agglutinin was detected, and the patient had a negative Donath-Landsteiner test. [ncbi.nlm.nih.gov]

  […] with giant cell arteritis: 10–20% of patients with polymyalgia rheumatica also have GCA References:[4][1][3] Clinical features Systemic symptoms Constitutional symptoms: fever, weight loss, night sweats Fatigue and malaise Depressed mood Symptoms of anemia [amboss.com]

  Others are anemia, depression and flu-like symptoms including appetite loss and resulting weight loss, fever and weakness. [wellstar.org]

• Loss of Appetite

  BACKGROUND: A 73-year-old, previously well woman was admitted to an emergency department because of a 3-month history of severe proximal girdle pain and stiffness with loss of appetite and weight. [ncbi.nlm.nih.gov]

  It may also cause other symptoms, including: extreme tiredness loss of appetite weight loss depression See your GP if you have pain and stiffness for more than a week. They'll try to find out what's causing it. [nhs.uk]

  Additional symptoms include: fatigue morning stiffness loss of appetite weight loss fever depression [fibromyalgia-symptoms.org]

• Jaw Claudication

  The patient should be asked about headaches, jaw claudication and visual disturbance. If there is any suspicion of GCA, urgent discussion with the rheumatologist should take place that day. [ncbi.nlm.nih.gov]

  Branches of the external and internal carotid arteries are particularly susceptible and their involvement leads to the classic manifestations of visual loss, headache, scalp tenderness, and jaw claudication. [1] Jaw claudication is a prominent symptom [doi.org]

  C 11 Patients older than 50 years with jaw claudication; diplopia; and temporal artery beading, prominence, and tenderness should have a temporal artery biopsy to diagnose GCA. [aafp.org]

• Night Sweats

  Fever, night sweats, and weight loss were not discriminating features and were equally distributed among the RA, PMR, and GCA patients. [dovepress.com]

  Other clues are fatigue, weight loss, a slight temperature, night sweats and feeling unwell. Giant cell arteritis (GCA) is a rare condition linked to PMR, caused by inflammation of medium and large arteries, usually in the head and neck. [saga.co.uk]

  The severity of individual symptoms, except those of pruritus and night sweats, was not affected by CHR or the number of blood counts that were controlled. [ajmc.com]

  sweats Fatigue and malaise Depressed mood Symptoms of anemia Musculoskeletal symptoms: new onset, symmetric pain Shoulder and pelvic girdle, neck Worse at night Morning stiffness (> 45 min) Subjective weakness ∼ 10–20% of patients with polymyalgia rheumatica [amboss.com]

  Other symptoms of PMR may include: Headache Fever and/or night sweats Fatigue and loss of energy Loss of appetite Depression Weight loss Mild anaemia. [southerncross.co.nz]

• Arthritis

  Arthritis Rheum 53 (2005): 33. [medicinenet.com]

  Arthritis Rheum 2007; 57: 1514-1519 24 Kreiner F, Galbo H. Effect of etanercept in polymyalgia rheumatica: a randomized controlled trial. Arthritis Res Ther 2010; 12: R176 25 Salvarani C, Macchioni P, Manzini C et al. [thieme-connect.com]

  In clinical practice, it can be challenging to distinguish PMR from elderly-onset rheumatoid arthritis. [practicalpainmanagement.com]

  To rule our rheumatoid arthritis, a substance in the blood called Rheumatoid Factor may be checked. This will be elevated in people with rheumatoid arthritis; however, it is normal in people with PMR. [southerncross.co.nz]

• Osteoporosis

  These complications include severe osteoporosis and uncontrolled diabetes mellitus. [symptoma.com]

  Of the examined comorbidities, only osteoporosis prevalence increased within 3 years. GC use for ≥ 3 years was reported in one-fourth of all the patients. [ncbi.nlm.nih.gov]

  Osteoporosis prophylaxis was prescribed to 183 patients (60.2%); 12 patients (3.9%) developed osteoporosis and 56 (18.4%) developed gastric symptoms that led to GP consultation. [bjgp.org]

  […] should improve as your dosage of prednisolone is decreased, although osteoporosis can be a persistent problem, particularly if you are over 65. [hse.ie]

• Morning Stiffness

  Patient-reported complaints of pain, morning stiffness, and physical and mental function are the best measures of disease activity and response to treatment. [symptoma.com]

  Among the factors, only morning stiffness duration > 45 min was an independent predictive factor. [ncbi.nlm.nih.gov]

  Along with morning stiffness and aching, the inflammatory process can be detected by analyzing the patient’s erythrocyte sedimentation rate (ESR). [britannica.com]

  Symptoms include aching muscles and morning stiffness in the shoulders, hips, neck and mid-body. Other symptoms reported include: general tiredness, weakness, weight loss, low grade fever. [vasculitis.org.uk]

• Myalgia

  The headache and myalgia were improving with corticosteroid treatment; however, a trans-sphenoidal surgery was performed due to visual field loss. [ncbi.nlm.nih.gov]

  However, adrenocorticosteroids have proved highly effective in reducing inflammation and in speeding recovery. polymyalgia rheumatica Polymyalgia Internal medicine A condition characterized by an abrupt onset of myalgia and arthralgia of the neck and [medical-dictionary.thefreedictionary.com]

• Muscle Weakness

  Polymyalgia rheumatica (PMR) is classified as diffuse soft tissue rheumatism with characteristic pain and stiffness of proximal extremities/muscles without muscle weakness or atrophy. [youtube.com]

  There is no true muscle weakness nor evidence of muscle disease on electromyography (EMG) or on biopsy. [healthcentral.com]

  It causes muscle pain, stiffness, and decreased mobility, particularly around the shoulders, upper arms, neck, lower back, thighs, and hips. It does not lead to muscle weakness, but causes intense pain. [mountsinai.org]

  Snapshot A 60-year-old woman presents to her physician's office for headache and muscle weakness. She reports that she usually never has headaches but recently started experiencing headaches in the morning about 2 weeks ago. [step2.medbullets.com]

• Headache

  There may also be a cranial headache, which affects the temporal and occipital arteries, causing a severe throbbing headache. Serious complications of polymyalgia rheumatica include arterial insufficiency, coronary occlusion, stroke, and blindness. [medical-dictionary.thefreedictionary.com]

  GCA patients may complain of fatigue, headache, and tenderness of the scalp. There is often particular pain around the temporal and occipital arteries. Headache is the most common complaint and has been seen in over 67% of patients. [clinicaladvisor.com]

  The headache and myalgia were improving with corticosteroid treatment; however, a trans-sphenoidal surgery was performed due to visual field loss. [ncbi.nlm.nih.gov]

  […] by the International Headache Society as a primary headache. [doi.org]

  Because of the disease association with GCA, it is important to see your doctor right away if you develop headaches, tenderness in the temples, changes in vision, jaw pain, or fever. [vasculitisfoundation.org]

• Seizure

  Central nervous system disease: seizures, cerebral vascular accidents. SSS and brain ischaemia. Intracranial vessels are involved only rarely. Peripheral nerve involvement is also rare. [patient.info]

  Documented complications of methylprednisolone include sudden death, cardiac arrhythmias, infection, seizures, avascular necrosis of the femoral head, anaphylaxis, psychiatric disorders, hyperglycaemia, and gastrointestinal disturbances. 5 16-18 Sudden [doi.org]

  In very rare cases, GCA involves the central nervous system (CNS), producing abnormal mental status, seizures, or strokes. [emedicine.com]

• Asthenia

  However, at that time, she started to complain of asthenia, abdominal cramping and pain on the left side, weight loss and bloody diarrhoea. A colonoscopy confirmed a diagnosis of left-sided UC. [ncbi.nlm.nih.gov]

  Muscle tenderness, peripheral synovitis, arthritis, carpal tunnel syndrome or distal tenosynovitis, as well as non-specific symptoms, such as fatigue, asthenia, malaise, low-grade fever, anorexia and weight loss, may be associated. [orpha.net]

  […] these symptoms are usually bilateral, and affect the upper arms, neck, pelvis girdle, hips, and thighs in 50–90% of cases The onset of symptoms is often rapid, generally over a few days Constitutional manifestations such as low-grade fever, fatigue, asthenia [thelancet.com]

There is no definitive diagnostic test for polymyalgia rheumatica [3]. A rapid response to corticosteroids is considered diagnostic. Lack of response may indicate an incorrect diagnosis [9] [10].

Laboratory studies [12]

• Erythrocyte sedimentation rate (ESR)
• C-reactive protein (CRP)
• Complete blood count (CBC) with differential
• Liver function tests
• Creatine kinase level
• Serum creatinine and urinalysis
• Thyroid function test
• Serum calcium
• Blood glucose

White blood cell count in polymyalgia rheumatica is normal or mildly elevated. Platelet count is increased indicating systemic inflammation [3] [12].

Erythrocyte sedimentation rate (ESR) is the test most sensitive for polymyalgia rheumatica, but is not specific. It may be elevated in any inflammatory disease and may not always be elevated in polymyalgia rheumatica [3] [4] [10].

Serum interleukin 6 (IL-6) levels are elevated and rise and fall with disease activity. This test is not readily available in all laboratories [10].

Antinuclear antibodies, rheumatoid factor, and anticyclic citrullinated peptide (anti-CCP) levels are usually normal [10].

Other procedures

Synovial fluid aspiration in patients with synovitis show signs of inflammation, white blood cell counts of 1,300-11,000 cells/µL, with 34% polymorphonuclear leukocytes [12].

Radiographic studies show normal joints or mild osteoarthritis. More extensive arthritis indicates other disorders such as rheumatoid arthritis.

Magnetic resonance imaging (MRI) is not necessary for diagnosis, but reveals bursitis and synovitis [12] [13].

Ultrasonography may be helpful for differential diagnosis. In polymyalgia rheumatica shoulder, bursa effusions may be seen [13].

There are no reliable tests for predicting the possible recurrence in polymyalgia rheumatica. Erythrocyte sedimentation rate (ESR) has been used for this, but results are inconsistent [9]. C-reactive protein and interleukin-6 may be more sensitive predictors [9].

• Thrombocytosis

  Most people with polymyalgia rheumatica have an unusually high number of these cells (thrombocytosis). On the other hand, many people with polymyalgia rheumatica have a lower number of red blood cells than normal and are often anemic. [web.archive.org]

  Such abnormalities can include a mild normocytic anemia due to chronic inflammation, leukocytosis, and thrombocytosis. Inflammatory markers (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]) frequently are elevated. [practicalpainmanagement.com]

  Hayreh 2003 points out that although essential thrombocytosis has increased thrombotic morbidity, the thrombocytosis in GCA is reactive and thus an antithrombotic agent is likely to have little effect. [doi.org]

  Anemia of chronic disease, leukocytosis, reactive thrombocytosis, and decreased albumin are also common. Alkaline phosphatase and hepatic enzymes may be elevated. [rheumaknowledgy.com]

  There is no evidence that the increase in other cell lines (leukocytosis, thrombocytosis) increases risk of thrombosis. [merckmanuals.com]

• Hypoalbuminemia

  Other laboratory signs of inflammation may include: thrombocytosis, leukocytosis, anemia, hypoalbuminemia, polyclonal hypergammaglobulinemia, and an elevated ferritin. [rheumatologyadvisor.com]

  She was admitted to hospital as" polymyalgia Rheumatica" and the lab tests showed anemia of hemoglobin (Hb) 87 g/L, hypoalbuminemia (Alb: 20 g/L), C-reactive protein (CRP) 75.9 mg/L, lactate dehydrogenase (LDH) 269 U/L, no other serum values abnormal [aclr.com.es]

• Normocytic Normochromic Anemia

  • The complete blood cell test reveals mild normocytic, normochromic anemia in 50% of cases. The white blood cell count may be normal or mildly elevated. [uspharmacist.com]

  Other laboratory findings are typical of systemic inflammation: increased concentrations of acute phase reactants (C-reactive protein, alpha2 globulins, fibrinogen), mild-to-moderate normocytic normochromic anemia, and elevation of the platelet count. [reliasmedia.com]

• Erythrocyte Sedimentation Rate Increased

  Advanced age, female sex, elevated erythrocyte sedimentation rate, increased plasma viscosity, high serum levels of soluble interleukin (IL)-6 receptor and persistently elevated C-reactive protein levels were associated with a higher relapse risk. [thieme-connect.com]

The diagnosis of polymyalgia rheumatica is often made after an extensive workup to exclude other diseases. This delays treatment and relief of symptoms [6].

The goal of treatment is to control pain, reduce stiffness, prevent systemic components, and prevent the effect of the disease on daily life [6] [11].

Corticosteroids are the treatment of choice, as they result in complete or near-complete symptom relief and normalization of erythrocyte sedimentation rate [3] [4]. Starting doses of prednisone of 10 to 15 mg/day are recommended [6]. Expect relief of symptoms within 24-72 hours. If symptoms are not well controlled within 1 week, steroid doses should be increased until they are [6] [14]. Once symptoms are controlled and erythrocyte sedimentation rates have dropped, slow tapering by 1 mg/month is recommended [14].

Inflammatory markers document the progression of the disease, but should not be used to decrease or stop treatment. Patient-reported complaints of pain, morning stiffness, and physical and mental function are the best measures of disease activity and response to treatment [3] [4] [6] [14].

Long-term high cumulative doses of corticosteroids have been associated with more adverse effects [6] [14]. If not contraindicated, non-steroidal anti-inflammatory medications may be used for supplemental pain relief [6] [14].

Corticosteroid-sparing agents in patients with polymyalgia rheumatica may reduce corticosteroid adverse effects. It is of particular benefit in diabetic patients or those with osteonecrosis [3] [5].

• Methotrexate at 7.5 mg/week along with prednisone showed decreased complications [15]. 
• Tumor necrosis factor alpha (TNF-α), Etanercept, reduces the cumulative dose of prednisone needed [15]. Results have been variable, but indicate the drug to be safe [10].

Relapses are common in polymyalgia rheumatica. Close, frequent follow-up is necessary to monitor for relapse and long-term complications of corticosteroid use. Medications for treatment of osteoporosis and gastrointestinal ulcer prophylaxis should be instituted as necessary [3] [4].

Diet

Calcium and vitamin D supplements should be prescribed for all patients with polymyalgia rheumatica on starting corticosteroid therapy [3] [4].

Activity

No activity restriction are recommended. Physical therapy for those with difficulty with mobility and activities of daily living may be needed.

Follow-up

Patients on corticosteroids should be followed monthly to track disease progress. After tapering of the steroid dosage, quarterly follow-up should be sufficient to identify possible relapses [5] [15].

Relapses occur in approximately 50% of patients, most often within 1 year of corticosteroid withdrawal. All patients should be monitored for symptom of recurrence during tapering of corticosteroids and for 12 months after therapy [5]. If symptoms recur prednisone is still the drug of choice [5].

Polymyalgia rheumatica is a chronic, recurring disorder. It may last as long as 2 years or more. Recurrences occur in 40-50% of patients [8]. Prognosis is generally good.

Adverse complications of corticosteroid use, osteoporotic fractures and diabetes mellitus, are common. One study reported 65% of patients had at least one serious corticosteroid complication [9].

Polymyalgia rheumatica has been associated with atherosclerosis and a higher risk of cardiovascular and cerebrovascular disease [2]. The use of corticosteroids may actually decrease this risk by controlling inflammation [2].

Quality of life, both physical and mental, may be affected by polymyalgia rheumatica. Pain and morning stiffness may reduce physical quality of life, while disability and decreased function may cause depression [7].

The symptoms of polymyalgia rheumatica are due to inflammation [3]. The exact cause of the inflammation is unknown. An autoimmune process may be involved in polymyalgia rheumatica because it is associated with a high level of Interleukin 6 (IL-6) [5].

The mean incidence of polymyalgia rheumatica is 52.5 cases per 100,000 persons 50 years and older, with a prevalence of 0.5-0.7% [4].

Polymyalgia rheumatica occurs most frequently in Caucasians, only occasionally occurring in Africans and Hispanics [4] [5] [6].
Polymyalgia rheumatica develops almost always in individuals over the age of 50 with the mean age of 72 years. The incidence of polymyalgia rheumatica increases with age [6] [7].

Women are affected two to three times more often than men [5] [6].

The exact cause is not known. Polymyalgia rheumatica presents as inflammation of the shoulders, hips, knees, and wrists. Inflammation is thought to start in response to an unknown antigen [3]. This disease is often associated with significantly elevated indicators of inflammation such as erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) [6]. Rapid response to corticosteroids is the only consistent diagnostic finding [6]. The lack of response to corticosteroids indicates the need to question the diagnosis [3].

A genetic component predisposing some individuals to the disorder is suspected because of the higher incidence among Northern Europeans and in family members [3] [5]. This hypothesis postulates that in genetically predisposed patients an environmental factor, possibly a virus, causes white blood cell activation with the production of cytokines [2].

An autoimmune process may also occur in polymyalgia rheumatica. Patients usually have an elevated Interleukin 6 level which is likely responsible for the systemic inflammatory response [2] [3] [5].

Polymyalgia rheumatica may be associated with the aging process as it occurs almost entirely in those over 50 years of age and the incidence increases with age.

Polymyalgia rheumatica cannot be prevented at this time. The pain, disability, and the effects on quality of life can be prevented with early diagnosis and prompt treatment.

The use of steroid-sparing agents, such as methotrexate may reduces the serious corticosteroid-related complications [9]. The prevention of and early treatment of osteoporosis and uncontrolled diabetes will potentially prevent the many, serious complications of these disorders.

Polymyalgia rheumatica is a common disorder of the elderly, individuals 50+ years [1] [2]. It is a chronic inflammatory disease of unknown etiology characterized by pain in the hip and shoulder girdles with morning stiffness that lasts for more than 1 hour [2].

Polymyalgia rheumatica affects the proximal muscles and joints, and may cause disability in older adults [3] [4]. It is diagnosed by the presenting symptoms and the exclusion of other diagnoses. A rapid response to corticosteroids, the treatment of choice, is considered diagnostic [1].

Polymyalgia rheumatica has an excellent prognosis [5]. However, recurrences are common [1] [2]. More than 50% of patients remain on steroids for 2 years or more [2].

Although the etiology of polymyalgia rheumatica is unknown, infectious or environmental agents may be triggers [6]. A genetic component is also suspected, as the disorder occurs more often in individuals of Northern European descent and in family members.

Polymyalgia rheumatica is often a co-morbid disorder with giant cell arteritis. Approximately 15% of patients with polymyalgia rheumatica develop giant cell arteritis and 40-50% of patients with giant cell arteritis have a history of polymyalgia rheumatica [1] [2].

What is polymyalgia rheumatica?

Polymyalgia rheumatica is a relatively common inflammatory disease of older adults. Peak incidence is after 50 years of age. It causes pain and morning stiffness of the shoulders, hips, neck, and wrists. It is a self-limited condition which resolves in months to several years with no residual effects. However, relapses occur in 40 to 50 % of patients.

What are the symptoms of polymyalgia rheumatica?

Symptoms of polymyalgia rheumatica include:

• Pain in the joints of the shoulders, hips, neck, and wrists
• Morning stiffness lasting longer than 1 hour
• Difficulty preforming activities of daily living
• Low-grade fever
• Weight loss
• Malaise
• Fatigue

What causes polymyalgia rheumatica?

The cause of polymyalgia rheumatica is unknown. There are several theories related to its occurrence. It is felt that polymyalgia rheumatica may be an autoimmune (the body’s immune system attacking itself) inflammatory disease triggered by an infection or environmental agent. Another theory purposes a genetic factor that predisposes certain individuals to acquiring the disease.

Who gets polymyalgia rheumatica?

Polymyalgia rheumatica occurs almost exclusively in individuals older than 50 years of age with a mean age of 72 years.
Polymyalgia rheumatica is twice as common in females as males.
It is primarily a disease of Caucasians, only occurring rarely in African Americans and Hispanics. The incidence of polymyalgia rheumatica is highest in those of Northern European descent.

How is polymyalgia rheumatica diagnosed?

There is no specific test for polymyalgia rheumatica. It is usually diagnosed by its presenting symptoms and the fact that they respond quickly to corticosteroid medications. Some blood tests that indicate inflammation will also be used to diagnose the disease and response to treatment.

How is polymyalgia rheumatica treated?

Polymyalgia rheumatica is treated almost exclusively with corticosteroids like prednisone. Other medications may be added to reduce the dose of prednisone needed.

What are the complications of polymyalgia rheumatica?

The complications of polymyalgia rheumatica include short-term disability associated with pain and stiffness and decreased quality of life.
Other complications are not a result of the disease itself, but to long-term corticosteroids use. These complications include severe osteoporosis and uncontrolled diabetes mellitus.

1. Gonzalez-Gay MA, Barros S, Lopez-Diaz MJ, Garcia-Porrua C, Sanchez-Andrade A, Llorca J. Giant cell arteritis: disease patterns of clinical presentation in a series of 240 patients. Medicine. 2005;84(5):269-76.
2. Gonzalez-Gay MA, Vazquez-Rodriguez TR, Lopez-Diaz MJ, Miranda-Filloy JA, Gonzalez-Juanatey C, Martin J, et al. Epidemiology of giant cell arteritis and polymyalgia rheumatica. Arthritis Rheum. 2009;61(10):1454-61.
3. Caylor TL, Perkins A. Recognition and management of polymyalgia rheumatica and giant cell arteritis. Am Fam Physician. 2013;88(10):676-84.
4. Gonzalez-Gay MA, Garcia-Porrua C, Miranda-Filloy JA, Martin J. Giant cell arteritis and polymyalgia rheumatica: pathophysiology and management. Drugs Aging. 2006;23(8):627-49.
5. Healey LA. Long-term follow-up of polymyalgia rheumatica: evidence for synovitis. Semin Arthritis Rheum. 1984;13(4):322-8.
6. Hernández-Rodríguez J, Cid MC, López-Soto A, Espigol-Frigolé G, Bosch X. Treatment of polymyalgia rheumatica: a systematic review. Arch Intern Med. 2009;169(20):1839- 45.
7. González-Gay MA, García-Porrúa C, Vázquez-Caruncho M, Dababneh A, Hajeer A, Ollier WE. The spectrum of polymyalgia rheumatica in northwestern Spain: incidence and analysis of variables associated with relapse in a 10 year study. J Rheumatol. 1999;26(6):1326-32.
8. Salvarani C, Cantini F, Niccoli L, Macchioni P, Consonni D, Bajocchi G, et al. Acute-Phase Reactants and the Risk of Relapse/Recurrence in Polymyalgia Rheumatica: A Prospective Followup Study. Arthritis & Rheumatism. 2005, 53, (1); 33–38.
9. Hancock AT, Mallen CD, Belcher J, Hider SL. Association Between Polymyalgia Rheumatica and Vascular Disease: A Systematic Review. Arthritis Care & Research, 2012, 64(9), 1301–1305.
10. Hutchings A, Hollywood J, Lamping DL, Pease CT, Chakravarty K, Silverman B, Choy DG, et al. Clinical Outcomes, Quality of Life, and Diagnostic Uncertainty in the First Year of Polymyalgia Rheumatica. Arthritis & Rheumatism. 2007, 57(5), 803–809.
11. Catanoso MG, Macchioni P, Boiardi L, Pipitone N, Salvarani C. Treatment of Refractory Polymyalgia Rheumatica With Etanercept: An Open Pilot Study. Arthritis & Rheumatism, 2007;57(8), 1514–1519.
12. Dasgupta B, Cimmino MA, Kremers HM, Schmidt WA, Schirmer M, Salvarani C, et al. Provisional Classification Criteria for Polymyalgia Rheumatica. Arthritis & Rheumatism, 2012; 64(4), 943–954.
13. Kennedy S. Polymyalgia rheumatica and giant cell arteritis: An in-depth look at diagnosis and treatment. Journal of the American Academy of Nurse Practitioners. 2012;24: 277–285.
14. Leeb B, Bird H, Nesher G, Ande I , Hueber W, Logar D, Montecucco C, et al. EULAR response criteria for polymyalgia rheumatica: results of an initiative of the European Collaborating Polymyalgia Rheumatica Group. Ann Rheum Dis. 2003; 62(12): 1189–1194. 
15. Caylor TL, Perkins A. Recognition and management of polymyalgia rheumatica and giant cell arteritis. Am Fam Physician. 2013; 88(10):676-84.