What are the treatment options for fibromyalgia?

Treatment Options for Fibromyalgia

The management of fibromyalgia should follow a graduated approach starting with aerobic and strengthening exercise as the first-line treatment, followed by other non-pharmacological therapies, and then adding pharmacological options for persistent symptoms. 1

Diagnosis and Initial Assessment

Fibromyalgia is characterized by:

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

Diagnosis requires:

• Pain present in all four body quadrants for at least 3 months
• Exclusion of other conditions (rheumatic disorders, systemic inflammatory conditions, hypothyroidism)
• No radiological or laboratory abnormalities specific to fibromyalgia

Treatment Algorithm

First-Line: Non-Pharmacological Approaches

1. Aerobic and Strengthening Exercise (Strong recommendation)

   • Most effective non-pharmacological intervention with strongest evidence 1
   • Start with low intensity and gradually increase
   • Options include walking, swimming, cycling
   • Aim for 2-3 sessions per week, 20-30 minutes per session

2. Patient Education

   • Explain the condition as a centralized pain syndrome
   • Emphasize that pain is real but not associated with tissue damage
   • Set realistic expectations about treatment outcomes

Second-Line: Additional Non-Pharmacological Options

1. Cognitive Behavioral Therapy (CBT)

   • Helps address unhelpful coping strategies and mood disorders
   • Weak recommendation but consistent evidence of benefit 1

2. Multicomponent Therapies

   • Combination of education, exercise, and psychological therapies
   • Weak recommendation but effective for pain reduction 1

3. Physical Therapies

   • Acupuncture or hydrotherapy
   • Weak recommendation but may benefit some patients 1

4. Meditative Movement Therapies

   • Yoga, tai chi, qigong
   • Mindfulness-based stress reduction
   • Weak recommendation but may improve symptoms 1

Third-Line: Pharmacological Options (for persistent symptoms)

1. First-Line Medications

   • Amitriptyline (low dose)

     • Weak recommendation but consistent evidence 1
     • Start at 10-25 mg at bedtime

   • Pregabalin

     • Weak recommendation 1
     • FDA-approved for fibromyalgia 2
     • Dosage: 300-450 mg/day (divided doses)
     • 44% of patients reported improvement vs. 35% with placebo 3
     • Common side effects: dizziness, somnolence, weight gain 2

   • Duloxetine

     • Weak recommendation 1
     • FDA-approved for fibromyalgia 4
     • Dosage: 60 mg once daily
     • More effective in patients with comorbid depression 4
     • No additional benefit from higher doses (120 mg) 4

2. Second-Line Medications

   • Milnacipran

     • Weak recommendation 1
     • Similar efficacy to duloxetine

   • Cyclobenzaprine

     • Weak recommendation 1
     • Similar to amitriptyline but with fewer anticholinergic effects

   • Tramadol

     • Weak recommendation 1
     • Limited evidence of efficacy
     • Risk of dependence and drug interactions 3

Important Considerations and Pitfalls

1. Avoid Ineffective Treatments

   • NSAIDs have no specific effect on fibromyalgia 3
   • Opioids (except tramadol) show no benefit and carry significant risks 5
   • Corticosteroids are not recommended 1

2. Treatment Expectations

   • Effects of most treatments are modest 1
   • Complete resolution of symptoms is rare
   • Focus on improving function and quality of life rather than eliminating pain

3. Medication Challenges

   • High discontinuation rates due to side effects (19-33% for pregabalin) 3
   • Benefits may diminish over time
   • Start at low doses and titrate slowly to minimize side effects

4. Comorbidities

   • Address sleep disorders, depression, and anxiety as they can worsen fibromyalgia symptoms
   • Tailor medication choice to target comorbid conditions (e.g., duloxetine for comorbid depression)

5. Monitoring and Follow-up

   • Regular reassessment of treatment efficacy
   • Adjust treatment based on response
   • Consider medication discontinuation trials after sustained improvement

Special Situations

• Severe Disability: Consider multimodal rehabilitation programs 1
• Predominant Sleep Disturbance: Prioritize amitriptyline or pregabalin
• Predominant Mood Disorders: Prioritize duloxetine or milnacipran
• Elderly Patients: Start with lower medication doses and monitor closely for side effects

By following this graduated approach and individualizing treatment based on predominant symptoms, most patients with fibromyalgia can experience meaningful improvements in pain, function, and quality of life.