What are the treatment options for fibromyalgia?

Treatment Options for Fibromyalgia

The most effective treatment for fibromyalgia is a graduated approach starting with aerobic and strengthening exercise as first-line therapy, followed by other non-pharmacological treatments and medications tailored to specific symptoms when necessary. 1

Diagnosis and Initial Assessment

Before initiating treatment, ensure proper diagnosis:

• Confirm widespread pain for at least 3 months
• Verify pain at 11 or more of the 18 specific tender point sites (ACR criteria)
• Rule out other conditions (rheumatic disorders, inflammatory conditions, hypothyroidism)
• Assess associated symptoms: fatigue, non-refreshed sleep, cognitive dysfunction, mood disturbances

Treatment Algorithm

First-Line Treatment (Strong Recommendation)

• Aerobic and strengthening exercise - The only intervention with strong evidence for effectiveness 1
  • Individually tailored exercise programs
  • Start with low intensity and gradually increase
  • Include both aerobic and strength training components
  • Aim for 2-3 sessions per week

Second-Line Treatments (Weak Recommendations)

If exercise alone is insufficient, add:

Non-Pharmacological Options

1. Cognitive behavioral therapy (CBT) 1

   • Addresses unhelpful thought patterns and coping strategies
   • Particularly useful for patients with mood disorders

2. Multicomponent therapies 1

   • Combination of educational or psychological therapies with exercise
   • More effective than single modalities for short-term relief

3. Physical therapies 1

   • Hydrotherapy/heated pool treatment
   • Acupuncture

4. Meditative movement therapies 1

   • Qigong, yoga, tai chi
   • Mindfulness-based stress reduction

Third-Line Treatments (Pharmacological Options)

When non-pharmacological approaches provide insufficient relief, consider medications:

1. First-choice medications (all have "weak for" recommendations) 1

   • Amitriptyline (low dose, 10-25 mg at bedtime)
   • Duloxetine (60-120 mg/day) or Milnacipran (100-200 mg/day) 2
   • Pregabalin (300-450 mg/day)

2. Second-choice medications 1

   • Tramadol - for pain management
   • Cyclobenzaprine - particularly for sleep disturbance

Treatments to Avoid

• Strong opioids - not recommended, risk of dependence without proven benefit 1, 3
• Corticosteroids - not recommended 1
• NSAIDs - no specific effect for fibromyalgia 3
• Homeopathy and guided imagery - strong recommendation against 1

Important Considerations and Pitfalls

1. Limited efficacy of all treatments

   • Even the most effective treatments show modest benefits 1, 3
   • The effect size for most pharmacological treatments is relatively small
   • Patient expectations should be managed appropriately

2. Medication side effects

   • Duloxetine/milnacipran: nausea, headache, insomnia, dry mouth 2
   • Pregabalin: dizziness, drowsiness, weight gain, peripheral edema
   • Amitriptyline: sedation, dry mouth, constipation, urinary retention

3. Treatment duration

   • Benefits of medications may diminish over time
   • Non-pharmacological approaches often require consistent long-term adherence
   • Regular reassessment is necessary

4. Comorbidities

   • Address sleep disturbances, depression, and anxiety specifically
   • These comorbidities can significantly impact treatment outcomes

5. Patient education

   • Acknowledge that the pain is real
   • Explain the centralized pain mechanism
   • Set realistic expectations about treatment outcomes

Special Populations

• Elderly patients: Start medications at lower doses and titrate slowly
• Patients with inflammatory arthritis: Treat the underlying condition first, then address fibromyalgia symptoms
• Patients with severe depression: Prioritize treatment of depression alongside fibromyalgia management

The evidence strongly suggests that a combination of non-pharmacological and pharmacological approaches is most effective for managing fibromyalgia 1, 4, 5, 6. However, exercise remains the cornerstone of treatment with the strongest evidence base 1.