What are the treatment options for fibromyalgia?

Treatment Options for Fibromyalgia

Optimal treatment for fibromyalgia requires a multidisciplinary approach with aerobic and strengthening exercise as the first-line intervention, followed by tailored pharmacological options for persistent symptoms. 1

Understanding Fibromyalgia

Fibromyalgia is a complex condition characterized by:

• Widespread pain
• Fatigue
• Non-refreshed sleep
• Mood disturbances
• Cognitive impairment ("fibro fog")

The condition involves abnormal pain processing and various secondary features that significantly impact quality of life.

Treatment Algorithm

First-Line: Non-Pharmacological Interventions

1. Exercise Therapy (strongest evidence)

   • Aerobic exercise and strength training have the strongest recommendation (Level Ia, Grade A) 1
   • Different exercise types target specific symptoms:
     • All exercise forms improve pain and depression
     • Mind-body and strengthening exercises best for fatigue
     • Aerobic and strengthening exercises best for sleep 2
   • Start with low intensity and gradually increase

2. Physical Therapies

   • Heated pool therapy/hydrotherapy (Level IIa, Grade B) 1
   • Balneotherapy shows significant improvement in pain and function 2

3. Psychological Interventions

   • Cognitive Behavioral Therapy (CBT) (Level Ia, Grade A) 1
   • Particularly effective for addressing mood disorders and unhelpful coping strategies

4. Complementary Approaches

   • Meditative movement therapies (yoga, tai chi, qigong) 1
   • Mindfulness-based stress reduction 1

Second-Line: Pharmacological Interventions (for persistent symptoms)

1. Antidepressants

   • Duloxetine (SNRI): Effective for pain reduction and improved function (Level Ib, Grade A) 1

     • FDA-approved for fibromyalgia
     • Dosage: 60 mg once daily (higher doses not more effective but have more side effects) 3

   • Amitriptyline (TCA): Low-dose (Level Ib, Grade A) 1

     • Start with 10-25 mg at bedtime

2. Anticonvulsants

   • Pregabalin (Level Ib, Grade A) 1
     • FDA-approved for fibromyalgia
     • Effective for pain reduction and improved sleep
     • Dosage: 300-450 mg/day (600 mg not more effective but has more side effects) 4

3. Pain Medications

   • Tramadol (Level Ib, Grade A) 1

     • Effective for pain management

   • Simple analgesics like acetaminophen may be considered 1

   • Avoid strong opioids and corticosteroids (not recommended) 1

Multicomponent Therapy

For patients with severe symptoms or disability, consider multicomponent therapy combining:

• Exercise
• Psychological interventions
• Pharmacotherapy
• Education

This approach has shown better outcomes than single modalities alone 1, 2

Important Considerations and Pitfalls

1. Medication Cautions:

   • Higher doses of duloxetine (120 mg) and pregabalin (600 mg) show no additional benefit but increase adverse effects 3, 4
   • Monitor for side effects: dizziness, somnolence, weight gain, dry mouth
   • Strong opioids are not recommended and may worsen outcomes 1

2. Exercise Implementation:

   • Common pitfall: Starting with too high intensity leading to symptom flares
   • Solution: Begin with very low intensity and gradually increase as tolerated

3. Treatment Expectations:

   • Set realistic expectations - treatments typically provide modest improvements rather than complete resolution
   • Focus on improving function and quality of life, not just pain reduction

4. Symptom-Specific Targeting:

   • For predominant fatigue: Focus on strengthening and mind-body exercises 2
   • For predominant sleep issues: Aerobic exercise and pregabalin 4, 2
   • For predominant mood issues: CBT and duloxetine 1, 3

Conclusion

The evidence strongly supports starting with exercise therapy, particularly aerobic and strengthening exercises, as the foundation of fibromyalgia treatment. For patients with inadequate response, add targeted pharmacological interventions based on predominant symptoms. The treatment approach should be sequential, starting with non-pharmacological options and adding medications only when necessary for symptom control.