What are the treatment options for fibromyalgia?

Treatment Options for Fibromyalgia

The management of fibromyalgia should follow a graduated approach starting with non-pharmacological therapies, particularly aerobic and strengthening exercise as the first-line treatment, followed by pharmacological options only when needed. 1

Initial Approach to Fibromyalgia Management

Non-Pharmacological Therapies (First-Line)

1. Exercise Therapy (strongest evidence)

   • Aerobic and strengthening exercise programs 1
   • Individually tailored to patient capabilities
   • Start with low intensity and gradually increase
   • Aim for 2-3 sessions per week

2. Cognitive Behavioral Therapy (CBT)

   • Helps address pain catastrophizing and improves coping strategies 1
   • Particularly beneficial for patients with mood disorders

3. Other Evidence-Based Non-Pharmacological Options

   • Multicomponent therapies (combining different approaches) 1
   • Hydrotherapy/heated pool treatment 1
   • Acupuncture 1
   • Meditative movement therapies (yoga, tai chi, qigong) 1
   • Mindfulness-based stress reduction 1

Pharmacological Therapies (Second-Line)

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

1. For Pain and Sleep Disturbance:

   • Amitriptyline (low dose, 10-25 mg at bedtime) 1
   • Pregabalin (150-450 mg/day in divided doses) 1
   • Cyclobenzaprine (5-10 mg at bedtime) 1

2. For Pain and Depression/Anxiety:

   • Duloxetine (60-120 mg/day) 1, 2
   • Milnacipran (100-200 mg/day) 1, 2

3. For Pain (Limited Evidence):

   • Tramadol (50-100 mg every 4-6 hours as needed) 1
   • Simple analgesics like paracetamol 1

Important Considerations and Caveats

1. Medications to Avoid:

   • NSAIDs have not demonstrated specific benefits for fibromyalgia 3, 4
   • Strong opioids are not recommended due to risk of dependence and lack of proven benefit 1, 4
   • Corticosteroids are not recommended 1

2. Treatment Expectations:

   • Set realistic expectations - treatments typically provide modest benefits
   • The goal is improvement in quality of life, not complete resolution of symptoms 1
   • Effects of medications are often limited and may diminish over time 3

3. Adverse Effects:

   • Monitor for side effects of medications:
     • Pregabalin: dizziness, drowsiness, weight gain (19-33% discontinuation rate) 3
     • Duloxetine/Milnacipran: nausea, dry mouth, constipation, headache 2
     • Amitriptyline: sedation, dry mouth, constipation, urinary retention

4. Treatment Algorithm:

   • Start with education about the condition
   • Implement exercise program as cornerstone therapy
   • Add CBT if available
   • If inadequate response after 4-6 weeks, add appropriate medication based on predominant symptoms
   • Reassess every 4-8 weeks and adjust treatment as needed
   • Consider multimodal approach for refractory cases

Special Populations

• Comorbid Inflammatory Arthritis: Continue with disease-modifying treatments for the inflammatory condition while addressing fibromyalgia symptoms separately 1
• Pregnancy: Focus exclusively on non-pharmacological approaches
• Elderly: Use lower starting doses of medications and titrate slowly

The EULAR guidelines emphasize that fibromyalgia requires prompt diagnosis and comprehensive assessment of pain, function, and psychosocial context 1, 5. Treatment should be tailored to individual symptoms and preferences, but the evidence most strongly supports exercise therapy as the foundation of treatment, with medications serving as adjunctive therapy when needed.