What are the treatment options for a fibromyalgia (Fibromyalgia Syndrome) flare-up?

From the Guidelines

To treat a fibromyalgia flare, focus on a combination of medication, rest, and stress management, prioritizing non-pharmacological approaches and considering pharmacological options like duloxetine, pregabalin, or milnacipran as needed, as recommended by the most recent guidelines 1. When managing a fibromyalgia flare, it's essential to consider the following key points:

• Medication: Take prescribed pain medications such as acetaminophen, NSAIDs like ibuprofen (400-800mg every 6-8 hours), or specific fibromyalgia medications like duloxetine (30-60mg daily), pregabalin (150-300mg daily in divided doses), or milnacipran (50-100mg twice daily) 1.
• Rest and stress management: Get adequate rest without completely stopping activity, as gentle movement prevents stiffness, and practice stress reduction techniques such as deep breathing, meditation, or gentle yoga 1.
• Heat therapy: Apply heat therapy using warm showers, heating pads, or warm compresses for 15-20 minutes several times daily to relax muscles and improve blood flow 1.
• Diet and hydration: Stay hydrated and maintain a balanced diet, avoiding potential trigger foods like processed items, excess caffeine, or alcohol 1.
• Tracking symptoms: Use a TENS unit on painful areas for 20-30 minutes at a time and track your symptoms and potential triggers in a journal to identify patterns 1. Fibromyalgia flares occur due to central sensitization, where your nervous system amplifies pain signals, so these interventions help calm this overactive pain response and reduce inflammation. It's crucial to contact your healthcare provider if flares are severe, persistent, or accompanied by new symptoms. The most recent guidelines emphasize the importance of a multidisciplinary approach, including non-pharmacological and pharmacological treatment modalities tailored to the individual patient's needs 1.

From the FDA Drug Label

The efficacy of pregabalin for management of fibromyalgia was established in one 14-week, double-blind, placebo-controlled, multicenter study (F1) and one six-month, randomized withdrawal study (F2) Studies F1 and F2 enrolled patients with a diagnosis of fibromyalgia using the American College of Rheumatology (ACR) criteria (history of widespread pain for 3 months, and pain present at 11 or more of the 18 specific tender point sites). The studies showed a reduction in pain by visual analog scale In addition, improvement was demonstrated based on a patient global assessment (PGIC), and on the Fibromyalgia Impact Questionnaire (FIQ).

To treat a fibromyalgia flare, consider the following:

• Pregabalin may be effective in reducing pain and improving patient global assessment and Fibromyalgia Impact Questionnaire scores.
• The recommended dose of pregabalin for fibromyalgia is not explicitly stated, but study F1 compared total daily doses of 300 mg, 450 mg, and 600 mg with placebo.
• Some patients experienced a decrease in pain as early as Week 1, which persisted throughout the study.
• Pregabalin treatment resulted in a longer time to loss of therapeutic response than treatment with placebo 2.
• Key points to consider when treating a fibromyalgia flare include:
  • Reducing pain
  • Improving patient global assessment
  • Improving Fibromyalgia Impact Questionnaire scores
  • Potential for dose-dependent adverse reactions
  • Individual patient response to treatment may vary 2

From the Research

Treatment Options for Fibromyalgia Flare

• Medications such as duloxetine, pregabalin, and milnacipran have been shown to be effective in managing fibromyalgia symptoms, including pain, fatigue, and sleep disturbances 3, 4, 5, 6, 7
• Duloxetine has been found to be the most effective treatment, improving pain, quality of life, and sleep quality, although it may have higher rates of discontinuation due to side effects such as nausea and dizziness 3, 7
• Pregabalin is beneficial for pain and sleep management, while milnacipran remains a viable option for those with predominant fatigue 3, 5
• Combination therapy, such as combining pregabalin with duloxetine, may also be effective in improving multiple clinical outcomes versus monotherapy 4
• Non-pharmacologic treatments, including fitness and strengthening exercise, warm-water therapy, and psychological pain management techniques, may also be beneficial in managing fibromyalgia symptoms 5

Pharmacological Approaches

• Serotonin and noradrenaline reuptake inhibitors, such as duloxetine, and pregabalin (an anticonvulsant) are FDA-approved medications for fibromyalgia treatment, targeting neurotransmitter modulation and central sensitization 6
• Analgesics, especially tramadol, may have a weak effect on pain, mainly in the short term 6
• Low-dose naltrexone and ketamine are gaining attention due to their action on neuroinflammation and depression modulation, but treatment protocols have not been validated 6
• Some treatments, such as opioids, steroids, and hormonal replacement, should be avoided due to the high risk of abuse and severe side effects 6

Comparative Studies

• Studies have compared the efficacy and safety of duloxetine and pregabalin in treating pain and depression in women with fibromyalgia, with duloxetine showing higher efficacy in improving pain symptoms 7
• However, pregabalin may have a lower dropout rate and cumulative incidence of nausea compared to duloxetine 7