What are the treatment options for fibromyalgia?

Treatment Options for Fibromyalgia

Exercise therapy should be the foundation of fibromyalgia treatment, with pharmacological options including low-dose amitriptyline, pregabalin, or duloxetine added based on symptom profile when non-pharmacological approaches provide inadequate relief. 1

First-Line Non-Pharmacological Treatments

Exercise Therapy

• Aerobic and strengthening exercise has the strongest evidence base for fibromyalgia treatment 1, 2
  • Start with low intensity and gradually increase
  • Aim for 2-3 sessions per week
  • Different exercise types target specific symptoms:
    • All exercise forms improve pain and depression (except flexibility exercises) 2
    • Mind-body and strengthening exercises improve fatigue 2
    • Aerobic and strengthening exercises improve sleep 2

Other First-Line Non-Pharmacological Options

• Patient education about fibromyalgia pathophysiology and realistic treatment goals 1
• Cognitive behavioral therapy for pain catastrophizing and improving coping strategies 1, 2
• Heated pool treatment/hydrotherapy 1
• Meditative movement therapies (yoga, tai chi, qigong) 1
• Mindfulness-based stress reduction 1, 2

Pharmacological Treatment

When to Add Medication

• Consider pharmacological therapy if inadequate response to non-pharmacological approaches after 4-8 weeks 1
• Select medications based on symptom profile:

First-Line Medications

1. Amitriptyline (10-25 mg at bedtime)

   • Beneficial for pain and sleep disturbance 1
   • Start with low dose to minimize side effects

2. Pregabalin (150-450 mg/day)

   • FDA-approved for fibromyalgia 1, 3
   • Demonstrated efficacy in reducing pain 3
   • Clinical trials showed 66-78% of patients experienced improvement vs. 47.6% with placebo 3
   • No evidence of greater effect at 600 mg vs. 450 mg daily, but increased side effects at higher doses 3

3. Duloxetine (60-120 mg/day)

   • FDA-approved for fibromyalgia 1, 4
   • Effective for pain and depression/anxiety 1
   • Studies show pain reduction as early as week 1 4
   • No additional benefit of 120 mg compared to 60 mg, with higher doses causing more adverse effects 4

4. Cyclobenzaprine (5-10 mg at bedtime)

   • Helpful for pain and sleep disturbance 1

5. Milnacipran (100-200 mg/day)

   • Recommended for pain and depression/anxiety 1

Treatment Algorithm

1. Begin with education and exercise therapy as the foundation
2. Add complementary non-pharmacological approaches based on specific symptoms
3. If inadequate response after 4-8 weeks, add pharmacological therapy:
   • For predominant sleep disturbance: Amitriptyline or cyclobenzaprine
   • For predominant pain without significant mood issues: Pregabalin
   • For pain with comorbid depression/anxiety: Duloxetine or milnacipran
4. Monitor and reassess every 4-8 weeks, adjusting treatment based on response and side effects

Important Considerations and Caveats

• Set realistic expectations: Treatments typically provide modest benefits (30-50% pain reduction is considered successful) 1
• Avoid ineffective treatments: Strong opioids and corticosteroids are not recommended due to risk of dependence and lack of proven benefit 1, 5
• NSAIDs and simple analgesics have limited evidence for effectiveness 1, 5
• Tramadol may be considered for pain management but should be used cautiously due to risk of dependence 1
• 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 while addressing fibromyalgia symptoms separately 1

Emerging Approaches

• Acupuncture (both somatic and abdominal) may be useful as a complementary treatment for pain management and improving quality of life 6, 7
• Multidisciplinary treatment approaches combining various therapies show promise for addressing the complex nature of fibromyalgia 2, 8

Remember that fibromyalgia is a complex condition characterized by central sensitization with altered pain processing. The goal of treatment is to improve quality of life rather than complete resolution of symptoms 1.