What are the treatment options for fibromyalgia?

Treatment Options for Fibromyalgia

A stepped approach to fibromyalgia management is recommended, with non-pharmacological interventions as the foundation and medications added selectively based on symptom profile and response. 1

Non-Pharmacological Therapies (First-Line)

• Exercise therapy: The strongest evidence supports aerobic and strengthening exercise as the foundation of fibromyalgia treatment 1

  • Should be individually tailored to patient capabilities
  • Start with low intensity and gradually increase
  • Aim for 2-3 sessions per week

• Cognitive behavioral therapy (CBT): Beneficial for patients with mood disorders 1

  • Helps address pain catastrophizing
  • Improves coping strategies

• Additional effective non-pharmacological approaches:

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

Pharmacological Therapies (Second-Line)

Medications should be considered if there is inadequate response to non-pharmacological approaches after 4-8 weeks 1:

• FDA-approved medications:

  • Pregabalin (150-450 mg/day): Demonstrated efficacy in reducing pain 1
  • Duloxetine (60-120 mg/day): Effective for pain and depression/anxiety 1, 2
  • Milnacipran (100-200 mg/day): Clinical trials showed at least 30% pain reduction compared to placebo 1, 3
    • Note: 100 mg/day is as effective as 200 mg/day 3

• Other recommended medications:

  • Amitriptyline (10-25 mg at bedtime): Effective for pain and sleep disturbance 1, 2
  • Cyclobenzaprine (5-10 mg at bedtime): Recommended for pain and sleep disturbance 1
  • Tramadol (50-100 mg every 4-6 hours as needed): May be considered for pain management, though evidence is limited 1

Treatment Algorithm

1. Initial approach:

   • Begin with patient education about fibromyalgia and realistic treatment goals
   • Implement exercise therapy as the foundation
   • Add complementary non-pharmacological approaches based on symptom profile

2. If inadequate response after 4-8 weeks:

   • Add pharmacological therapy based on predominant symptoms:
     • For pain + sleep disturbance: Amitriptyline or cyclobenzaprine
     • For pain + depression/anxiety: Duloxetine or milnacipran
     • For pain as primary symptom: Pregabalin

3. Monitor and reassess every 4-8 weeks:

   • Make adjustments based on response and side effects
   • Set realistic expectations - treatments typically provide modest benefits (30% pain reduction)
   • Goal is improving quality of life, not complete resolution of symptoms

Important Caveats

• Strong opioids are not recommended due to risk of dependence and lack of proven benefit 1

• Corticosteroids are not recommended for fibromyalgia management 1

• NSAIDs have not demonstrated benefits for fibromyalgia 2

• Special populations:

  • In pregnancy: Focus exclusively on non-pharmacological approaches 1
  • In elderly: Use lower starting doses of medications and titrate slowly 1
  • With comorbid inflammatory arthritis: Continue disease-modifying treatments for the inflammatory condition while addressing fibromyalgia symptoms separately 1

• Diet modifications may play a role in symptom management, with emphasis on anti-inflammatory diets 4, though this has less robust evidence than the approaches above