Which specialties manage fibromyalgia and fibromuscular dysplasia (FMD) of the cervical artery?

Management of Fibromyalgia and Fibromuscular Dysplasia of Cervical Artery

Fibromyalgia should be managed by rheumatologists, while fibromuscular dysplasia (FMD) of the cervical artery requires management by vascular specialists, neurologists, and interventional radiologists in a multidisciplinary approach. 1, 2

Fibromyalgia Management

Specialty Care

• Primary specialty: Rheumatology - responsible for diagnosis, treatment planning, and ongoing management 2, 1
• Supporting specialties:
  • Physical medicine and rehabilitation - for exercise therapy and physical modalities
  • Psychiatry/psychology - for cognitive behavioral therapy and management of comorbid mood disorders
  • Pain medicine - for refractory cases requiring specialized pain interventions

Treatment Approach

1. First-line treatments (non-pharmacological):

   • Aerobic and strengthening exercises (2-3 sessions/week, 10-30 minutes per session) 1
   • Patient education about the condition
   • Cognitive behavioral therapy (8-12 weekly sessions) 1

2. Second-line treatments:

   • Pharmacological options:
     • Pregabalin (150-450 mg/day) - FDA-approved 1
     • Duloxetine (60-120 mg/day) - FDA-approved 1
     • Milnacipran (100-200 mg/day) - FDA-approved 1
     • Amitriptyline (10-25 mg at bedtime) 1

3. Additional therapies:

   • Hydrotherapy or pool-based exercise (30-60 minutes, 2-3 times weekly) 1
   • Mindfulness-based stress reduction 1
   • Mediterranean-style diet 1

Fibromuscular Dysplasia of Cervical Artery Management

Specialty Care

• Primary specialties:
  • Vascular medicine/surgery - for overall management and surgical interventions if needed
  • Neurology - for management of neurological symptoms and complications
  • Interventional radiology - for diagnostic angiography and endovascular procedures

Diagnostic Approach

• Contrast-enhanced CTA, MRA, or catheter-based contrast angiography are the preferred diagnostic methods 2
• Annual noninvasive imaging is recommended initially to detect changes in disease extent or severity 2

Treatment Approach

1. For asymptomatic patients:

   • Antiplatelet therapy (optimal drug and dosing not established) 2
   • Regular imaging surveillance
   • Revascularization is NOT recommended for asymptomatic FMD regardless of stenosis severity 2

2. For symptomatic patients (with retinal or hemispheric cerebral ischemic symptoms):

   • Antiplatelet therapy
   • Carotid angioplasty with or without stenting 2
   • Monitoring for complications such as dissection, aneurysm formation, or stroke 3, 4

Important Considerations

For Fibromyalgia

• Set realistic expectations - treatments typically provide modest benefits rather than complete resolution 1
• Monitor response every 4-8 weeks; a 30% reduction in symptoms is considered clinically meaningful 1
• Avoid strong opioids and corticosteroids due to lack of proven benefit and risk of dependence 1

For Cervical FMD

• FMD is a systemic arterial disease; patients should be screened for involvement of other vascular beds, particularly renal arteries (present in 43% of patients with cervicocephalic FMD) 4
• Risk of stroke, arterial dissection, and aneurysm formation requires vigilant monitoring 4
• Patients with FMD have a higher risk of stroke and disease progression than previously thought 4

Pitfalls to Avoid

• Misdiagnosing FMD as atherosclerotic disease - FMD is a non-inflammatory, non-atherosclerotic condition affecting primarily middle-aged women 3, 5
• Failing to screen for multisystem involvement in FMD patients 4, 5
• Overreliance on pharmacological therapy alone for fibromyalgia - a combined approach with non-pharmacological interventions is essential 2, 1
• Performing revascularization for asymptomatic FMD, which is specifically not recommended 2

The management of both conditions requires ongoing monitoring and adjustment of treatment strategies based on symptom response and disease progression.