What are the treatment options for fibromyalgia?

Treatment Options for Fibromyalgia

Exercise therapy, particularly aerobic and strengthening exercises, is the strongest recommended treatment for fibromyalgia, followed by a combination of non-pharmacological and pharmacological approaches tailored to specific symptoms. 1

First-Line Treatment Approach

Non-Pharmacological Interventions

1. Exercise Therapy (Strong recommendation)

   • Aerobic exercise and strength training 1
   • Individually tailored programs 1
   • Heated pool therapy (particularly effective) 1

2. Psychological Interventions

   • Cognitive behavioral therapy (CBT) 1
   • Mindfulness-based stress reduction 1

3. Physical Therapies

   • Acupuncture 1
   • Hydrotherapy 1
   • Multicomponent therapies combining different approaches 1

Second-Line: Pharmacological Options for Specific Symptoms

When non-pharmacological approaches provide insufficient relief, add medications based on predominant symptoms:

1. For Pain and Sleep Disturbance:

   • Low-dose amitriptyline (tricyclic antidepressant) 1
   • Pregabalin 1

2. For Pain and Fatigue:

   • Duloxetine or milnacipran (SNRIs) 1
   • Milnacipran has demonstrated efficacy in clinical trials with significant pain reduction compared to placebo 2

3. For Pain with Poor Response to Above:

   • Tramadol (weak opioid) 1
   • Cyclobenzaprine (muscle relaxant) 1

Treatment Algorithm Based on Symptom Predominance

1. Pain-dominant presentation:

   • Start with aerobic exercise + CBT
   • If inadequate response: Add pregabalin or duloxetine
   • For partial response: Consider tramadol as adjunct

2. Fatigue-dominant presentation:

   • Start with graded exercise program + mindfulness
   • If inadequate response: Add duloxetine or milnacipran

3. Sleep disturbance-dominant:

   • Start with sleep hygiene + meditative movement therapies
   • If inadequate response: Add low-dose amitriptyline or pregabalin

Important Considerations and Pitfalls

1. Avoid ineffective treatments:

   • NSAIDs have no specific effect for fibromyalgia pain 3
   • Strong opioids are not recommended due to risk of dependence without proven benefit 1, 4
   • Corticosteroids are not recommended 1

2. Medication limitations:

   • Effect sizes for most medications are modest 1
   • Pregabalin has significant adverse effects (drowsiness, dizziness, weight gain) with 19-33% discontinuation rates 3
   • Tramadol shows limited efficacy and carries risks of dependence and drug interactions 3

3. Treatment expectations:

   • Set realistic goals - complete resolution of symptoms is uncommon
   • Focus on improving function and quality of life rather than eliminating pain
   • Treatment benefits may diminish over time, requiring periodic reassessment 1

Special Populations

1. Fibromyalgia with comorbid depression/anxiety:

   • Prioritize SNRIs (duloxetine, milnacipran) or amitriptyline
   • Intensify psychological interventions

2. Fibromyalgia with significant cognitive dysfunction:

   • Emphasize cognitive training alongside standard therapies
   • Consider duloxetine which may have beneficial effects on cognition

Research Gaps

Current evidence has identified several important research gaps 1:

• Which type of exercise is most effective
• Whether combined approaches are superior to single modalities
• How to predict which patients will respond to specific therapies
• Management of fibromyalgia as a comorbidity to inflammatory arthritis

Despite these gaps, the current evidence strongly supports starting with exercise therapy and adding other interventions based on predominant symptoms and response.