In large vessel vasculitis, including giant cell arteritis and Takayasu arteritis, as well as in polymyalgia rheumatica, glucocorticoid therapy is the treatment of choice. However, there are two situations/questions for additional immunosuppressive therapies in these diseases: (i) therapy resistance to glucocorticoid mono-therapy; (ii) situations which call for sparing of glucocorticoids such as in complications of glucocorticoid therapy. This review summarises the current scientific debate on the effects of methotrexate in these diseases. Methotrexate at 10-15 mg/week appears to have a modest and delayed effect in GCA and PMR in reducing relapse rate and lowering the cumulative dose of glucocorticoid therapy. However, superiority of combination therapy in reducing the incidence of glucocorticoid-related complications has not been shown yet. The effects of higher doses and long-time effects as well as the efficacy in patients with glucocorticoid-resistance and complications are unclear. Methotrexate may thus be considered as adjunctive therapy to glucocorticoid therapy in glucocorticoid-resistance or complications. Further attempts should be made for a better identification of patients with glucocorticoid-refractory courses and a more precise formulation of guidelines on indication, optimal dosing and duration.