Symptoms
The disease onset typically manifests as weakness of the ocular muscles before progressing to more generalised weakness in the majority of patients with gMG.1,3
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Ocular
muscles

Ocular muscles

  • Blurry or double vision (diplopia)
  • Eyelid drooping (ptosis)
  • Eye muscle weakness
  • Fatigability

Facial
muscles

Facial muscles

  • Drooping
  • Difficulty making facial expressions
  • Poor cheek puff
  • Drooling

Respiratory
muscles

Respiratory muscles

  • Fatigability
  • Pain holding head up
  • Diaphragm weakness/difficulty breathing (exertional dyspnoea, orthopnoea, tachypnoea)
  • Respiratory failure

Upper limb
muscles

Upper limb muscles

Arms

  • Cramps
  • Difficulty lifting
  • Fatigability
  • Fatigue
  • Pain
  • Spasms
  • Weakness (e.g. picking things up)

Hands and fingers

  • Dexterity
  • Fine motor skills (e.g. grasping)
  • Fatigability
  • Loss of strength
  • Spasms

Bulbar
muscles

Bulbar muscles

Voice and speech

  • Fatigability
  • Speech impairment (dysarthria)
  • Voice quality/tone
  • Hoarseness (dysphonia)

Chewing

  • Difficulty chewing
  • Jaw fatigue
  • Weakness

Swallowing

  • Difficulty swallowing (dysphagia)
  • Choking
  • Aspirating
  • Vomiting

Axial
muscles

Axial muscles

  • Fatigability
  • Pain holding head up
  • Weakness
  • Neck flexion
  • Neck extension/head drop

Back &
shoulder muscles

Back and shoulder muscles

  • Fatigue
  • Pain
  • Spasms
  • Weakness

Core
muscles

Core muscles

  • Weakness

Lower
limb muscles

Lower limb muscles

Hips

  • Fatigue
  • Pain
  • Spasms
  • Weakness

Legs and feet

  • Cramps
  • Fatigability
  • Fatigue
  • Pain
  • Spasms
  • Twitches
  • Weakness

Overall symptoms

Overall symptoms (location unspecified or described as general experience)

  • Cognitive impairment (difficulty focusing, memory)
  • Fatigability (worsening of impairment)
  • Mental fatigue (too exhausted to think or mentally motivate)
  • Pain (general muscle soreness or achiness)
  • Physical fatigue (lack of energy, a feeling of depletion, or lethargy)
  • Weakness (overall strength)

Adapted from Jackson, K. et al. Neurol Ther; 2023;12:107–128.

gMG symptoms are constantly in flux and external factors can trigger exacerbations:2,5,6

  • Patients have reported that hot or humid weather triggers general physical fatigue and muscle weakness
  • Some foods (due to their texture) can trigger difficulty chewing or swallowing
  • Stress and anxiety have also been reported to exacerbate muscle weakness
Anti–infective agents
Antirheumatics
Cardiovascular agents
Neuromuscular blockers
Topical eye preparations
These drugs are best avoided, and in circumstances where these therapies are essential, patients should be closely monitored for symptom exacerbation.6
The clinical manifestations of gMG are highly variable, both within the course of a day and over longer periods.2,4 Many patients can experience exacerbation of their symptoms either spontaneously or as a result of a triggering factor, such as during periods of illness or emotional stress, and in response to certain medications or surgeries.2,7 Exacerbations are common during the first year of the disease, while disease severity typically reaches its maximum within the first 2 years of disease onset.2
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Signs that a patient is at risk of myasthenic crisis include:8

  • Rapid worsening of primary myasthenic symptoms
  • Rapid progression of bulbar symptoms
  • Increasing dose of acetylcholinesterase inhibitors
  • Tachypnoea
  • Tachycardia
  • Decreased forced vital capacity
  • Respiratory infection
Learn more
ACh, acetylcholine; AChR, acetylcholine receptor; gMG, generalised myasthenia gravis; MG, myasthenia gravis.
Melzer N, et al. Clinical features, pathogenesis, and treatment of myasthenia gravis: A supplement to the Guidelines of the German Neurological Society. J Neurol. 2016;263(8):1473–1494. Meriggioli MN, Sanders DB. Autoimmune myasthenia gravis: Emerging clinical and biological heterogeneity. Lancet Neurol. 2009;8(5):475–490. Lazaridis K, Tzartos SJ. Autoantibody specificities in myasthenia gravis; implications for improved diagnostics and therapeutics. Front Immunol. 2020;11:212.
 Li Y, Arora Y, Levin K. Myasthenia gravis: Newer therapies offer sustained improvement. Cleve Clin J Med. 2013;80(11):711–721. Jackson K, et al. Understanding the symptom burden and impact of myasthenia gravis from a patient's perspective: A qualitative study. Neurol Ther. 2023;12:107–128. Sathasivam S. Diagnosis and management of myasthenia gravis. Prog Neurol Psychiatry. 2014;18:6–14. Abuzinadah AR, et al. Exacerbation rate in generalized myasthenia gravis and its predictors. Eur Neurol. 2021;84(1):43–48. Spillane J, et al. Myasthenia gravis. BMJ. 2012;345:e8497. Huang Y, et al. Patients with myasthenia gravis with acute onset of dyspnea: Predictors of progression to myasthenic crisis and prognosis. Front Neurol. 2021;12:767961.