What are the treatment options for fibromyalgia?

Treatment Options for Fibromyalgia

The management of fibromyalgia requires a multidisciplinary approach with initial focus on non-pharmacological therapies, particularly aerobic and strengthening exercise as first-line treatment, followed by pharmacological options only when needed. 1

First-Line Treatment: Non-Pharmacological Approaches

Exercise Therapy

• Aerobic and strengthening exercise has the strongest evidence and should be the foundation of fibromyalgia treatment 2, 1
• Exercise should be individually tailored, starting with low intensity and gradually increasing to 2-3 sessions per week 1
• Different types of exercise show different benefits:
  • All forms of exercise improve pain and depression 3
  • Mind-body and strengthening exercises specifically improve fatigue 3
  • Aerobic and strengthening exercises improve sleep 3

Other Effective Non-Pharmacological Options

• Cognitive behavioral therapy (CBT) - particularly beneficial for patients with mood disorders 2, 1
• Hydrotherapy/heated pool treatment - effective for pain reduction 2
• Acupuncture - recommended with moderate evidence 2, 1
• Meditative movement therapies (yoga, tai chi, qigong) and mindfulness-based stress reduction 2, 1
• Multicomponent therapies combining different approaches 2, 1

Second-Line Treatment: Pharmacological Options

For Pain and Sleep Disturbance

• Amitriptyline (low dose, 10-25 mg at bedtime) 2, 1
• Pregabalin (150-450 mg/day) - FDA approved for fibromyalgia with demonstrated efficacy in reducing pain 2, 1, 4
• Cyclobenzaprine (5-10 mg at bedtime) 2, 1

For Pain and Depression/Anxiety

• Duloxetine (60-120 mg/day) - FDA approved with demonstrated efficacy in reducing pain and improving function 2, 1, 5
• Milnacipran (100-200 mg/day) 2, 1

For Pain Management

• Tramadol (50-100 mg every 4-6 hours as needed) - recommended with caution 2, 1
• Simple analgesics like paracetamol may be considered, though evidence is limited 2, 1

Medications to Avoid

• Strong opioids - not recommended due to risk of dependence and lack of proven benefit 2, 1, 6
• Corticosteroids - not recommended for fibromyalgia management 2, 1
• NSAIDs - have not demonstrated benefits specifically for fibromyalgia 6

Treatment Algorithm

1. Begin with patient education about the nature of fibromyalgia and realistic treatment goals
2. Initiate exercise therapy - aerobic and strengthening exercises as the foundation
3. Add complementary non-pharmacological approaches based on symptom profile:
   • For stress/anxiety: Add CBT, mindfulness, or meditative movement
   • For physical function limitations: Add hydrotherapy or physical therapy
4. If inadequate response after 4-8 weeks, consider adding pharmacological therapy:
   • For predominant pain with sleep disturbance: Amitriptyline or pregabalin
   • For predominant pain with depression: Duloxetine or milnacipran
   • For muscle stiffness: Consider cyclobenzaprine
5. Monitor and reassess every 4-8 weeks, adjusting treatment based on response and side effects

Treatment Expectations

• Set realistic expectations - treatments typically provide modest benefits with the goal of improving quality of life, not complete symptom resolution 1
• Benefits of both pharmacological and non-pharmacological treatments are often modest, requiring combination approaches 7
• Symptom improvement may begin as early as 1 week with some medications but typically requires consistent treatment over time 4, 5

Common Pitfalls to Avoid

1. Relying solely on medications without implementing exercise therapy
2. Using opioids or NSAIDs as primary treatment
3. Failing to address sleep disturbances, which can worsen pain
4. Not providing adequate patient education about the chronic nature of fibromyalgia
5. Overlooking psychological aspects of pain management

The evidence clearly supports a stepped approach to fibromyalgia management, with non-pharmacological interventions as the foundation and medications added selectively based on symptom profile and response.