When the Temporal Artery Biopsy is Negative: A Case Series of Headache Attributed to Polymyalgia Rheumatica

Older adults presenting with a new or changed headache pattern in the setting of a diagnosis of polymyalgia rheumatica (PMR) are at risk for incident giant cell arteritis. However, the differential diagnosis of headache has not been evaluated in patients with a negative temporal artery biopsy (TAB). Headache has not been described as a symptom of PMR.

After prospectively identifying an individual felt to have headache attributed to PMR, we performed a chart review to identify additional cases. As a secondary outcome, we summarized alternative headache diagnoses in patients with PMR, headache and a negative TAB.

A 75-year-old woman presented with a subacute history of radiating cervical pain in the setting of a 3 month history of lower back stiffness at rest and fatigue. Clinical examination was suggestive of a cervicogenic headache. Following treatment with low-dose corticosteroid for PMR, headaches, cervical mobility and systemic findings resolved with treatment of PMR with low-dose corticosteroid. In our cohort of 36 patients, we identified a single additional patient meeting our study criteria for headache attributed to PMR. Three additional patients met all but 1 diagnostic criterion. The retrospective case was a 73-year-old woman with a subacute history of both morning-predominant headaches and muscle stiffness, diagnosed with PMR. Headaches remitted with low-dose corticosteroid and relapsed with corticosteroid taper.

Headache attributed to PMR is a steroid-responsive syndrome which should be considered in an older adult presenting with features of PMR, when the TAB is negative. Diagnostic criteria for headache attributed to PMR are proposed.