What are the symptoms and treatment options for fibromyalgia?

Symptoms and Treatment Options for Fibromyalgia

Fibromyalgia is characterized by chronic widespread pain as the dominant symptom, along with fatigue, non-refreshed sleep, mood disturbance, and cognitive impairment, which significantly impact quality of life. 1

Key Symptoms

Primary Symptoms

• Widespread Pain

  • Must be present on both sides of the body
  • Above and below the waist
  • Axial skeletal pain must be present
  • Duration must exceed 3 months 1

• Fatigue - Persistent, often severe, not relieved by rest 1

• Sleep Disturbances

  • Non-refreshed sleep
  • Insomnia
  • Poor sleep quality 1, 2

• Cognitive Dysfunction ("Fibro fog")

  • Memory problems
  • Difficulty concentrating
  • Mental clarity issues 1, 3

Associated Symptoms

• Mood disturbances (depression, anxiety)
• Morning stiffness
• Headaches
• Paresthesia (tingling sensations)
• Irritable bowel symptoms
• Irritable bladder or interstitial cystitis
• Temporomandibular disorder 2, 4

Diagnostic Approach

The diagnosis of fibromyalgia has evolved from requiring 11 of 18 tender points to newer criteria focusing on:

1. Widespread Pain Index (WPI) ≥ 7 AND Symptom Severity (SS) scale ≥ 5
2. Symptoms present at similar level for at least 3 months
3. No other disorder that would otherwise explain the pain 4

Treatment Algorithm

First-Line Treatment: Non-Pharmacological Approaches

1. Exercise - The only intervention with strong recommendation based on meta-analyses 1

   • Individually tailored aerobic exercise and strength training
   • Heated pool treatment with or without exercise 1
   • Start with low intensity and gradually increase

2. Patient Education

   • About the condition
   • Self-management strategies
   • Setting realistic expectations 1

Second-Line Treatment (if inadequate response)

Based on predominant symptoms:

1. For Pain

   • Pregabalin - FDA approved for fibromyalgia, reduces pain and improves function 5
   • Tramadol - Recommended for pain management (Grade A evidence) 1
   • Simple analgesics like paracetamol may be considered
   • Strong opioids and corticosteroids are NOT recommended 1

2. For Sleep Disturbances and Pain

   • Amitriptyline - Grade A evidence for pain reduction and functional improvement 1
   • Cyclobenzaprine - Weak recommendation, may improve sleep more than pain 1

3. For Mood Disorders and Pain

   • Duloxetine - SNRI with Grade A evidence 1
   • Milnacipran - SNRI with Grade A evidence 1, 6
   • Fluoxetine - May reduce pain and improve function 1

Third-Line Treatment (for severe disability)

• Multimodal Rehabilitation Program combining:
  • Cognitive Behavioral Therapy
  • Physical therapy
  • Psychological support
  • Pharmacotherapy 1

Treatment Pitfalls and Caveats

1. Medication Effectiveness

   • Effect size for most treatments is relatively modest 1
   • Benefits must be weighed against side effects
   • SNRIs like milnacipran carry risk of suicidal ideation, especially in younger patients 6

2. Diagnostic Challenges

   • Diagnosis often delayed (>2 years with average of 3.7 consultations) 1
   • Excessive testing and specialist referrals increase healthcare costs

3. Treatment Expectations

   • No known cure for fibromyalgia 2
   • Focus on symptom management and functional improvement
   • Shared decision-making with patients is essential 1

4. Monitoring

   • Regular assessment of treatment response
   • Adjust therapy based on predominant symptoms
   • Watch for medication side effects, particularly with SNRIs 6

The management of fibromyalgia requires addressing multiple symptoms with a structured approach starting with non-pharmacological interventions, particularly exercise, and adding targeted pharmacotherapy based on predominant symptoms when necessary.