Managing Fatigue in Fibromyalgia
For managing fatigue in fibromyalgia, a combination of non-pharmacological approaches (particularly exercise) as first-line therapy with selective pharmacological interventions (particularly pregabalin and duloxetine) offers the most effective treatment strategy.
Non-Pharmacological Interventions for Fatigue
Exercise Therapy (First-Line)
- Aerobic and strengthening exercise has the strongest evidence for treating fibromyalgia symptoms including fatigue 1
- Should be individually tailored, starting with low intensity and gradually increasing
- Aim for 2-3 sessions per week
- Particularly effective when combined with cognitive behavioral approaches
Other Non-Pharmacological Options
- Meditative movement therapies (yoga, tai chi, qigong) can reduce fatigue 1
- Hydrotherapy combining relaxation and exercise techniques 1
- Cognitive behavioral therapy to address pain catastrophizing and improve coping strategies 1
- Patient education about the nature of fibromyalgia and realistic treatment goals 1
Pharmacological Interventions for Fatigue
First-Line Medications
Pregabalin (150-450 mg/day) - FDA-approved for fibromyalgia with high-quality evidence showing small but significant benefit on fatigue (SMD -0.14; -0.19 to -0.08) 2, 3
Duloxetine (60-120 mg/day) - FDA-approved for fibromyalgia with evidence of effectiveness for fatigue 1, 5
- Most effective at 60 mg once daily (higher doses don't show additional benefit) 5
- Particularly beneficial when depression is a comorbidity
Second-Line Medications
Amitriptyline (10-25 mg at bedtime) - Moderate evidence for effectiveness in fibromyalgia 1
- Low cost option with benefits for sleep disturbance and fatigue
- Limited by anticholinergic side effects
Milnacipran (100-200 mg/day) - FDA-approved for fibromyalgia with evidence for fatigue reduction 1, 2
- Consider when both pain and fatigue are prominent symptoms
Other Medication Options
Cyclobenzaprine (5-10 mg at bedtime) - Moderate evidence for effectiveness 1
- Structurally similar to tricyclic antidepressants
- Particularly helpful when muscle spasms contribute to fatigue
Selective serotonin reuptake inhibitors (SSRIs) - Moderate effect on fatigue (SMD 0.48; 0.35 to 0.60) 2
- Consider when depression is a prominent comorbidity
Treatment Algorithm
Start with non-pharmacological approaches:
- Begin with graded exercise program
- Add patient education about fibromyalgia
- Consider cognitive behavioral therapy
If fatigue persists after 4-8 weeks, add pharmacological therapy:
- First choice: Pregabalin 150 mg/day, titrate up to 300-450 mg/day as needed
- Alternative first choice (especially with comorbid depression): Duloxetine 30 mg/day, titrate to 60 mg/day
If inadequate response after 4-8 weeks on optimal dose:
- Consider switching to alternative first-line agent
- Consider adding low-dose amitriptyline (10-25 mg) at bedtime
For refractory fatigue:
- Consider combination therapy (e.g., pregabalin plus duloxetine)
- Re-evaluate for other causes of fatigue (sleep disorders, anemia, hypothyroidism)
Monitoring and Expectations
- Assess response every 4-8 weeks 1
- A 30% reduction in fatigue is considered clinically meaningful 1
- Set realistic expectations - treatments typically provide modest benefits rather than complete resolution 1
- Monitor for side effects, particularly dizziness and somnolence with pregabalin, and nausea with duloxetine
Important Considerations
- Avoid opioids and corticosteroids as they are not recommended for fibromyalgia 2, 1
- NSAIDs have not demonstrated benefits for fibromyalgia symptoms including fatigue 6
- Combination therapy is often needed to address the multiple symptoms of fibromyalgia 7
- Treatment should target the most troublesome symptoms for each patient
Remember that no single treatment completely resolves all fibromyalgia symptoms, and a combination approach addressing both fatigue and other symptoms (pain, sleep disturbance, mood) is most effective 7, 8.