What are the signs, symptoms, and treatment options for fibromyalgia?

Signs and Symptoms of Fibromyalgia

Fibromyalgia is characterized by chronic widespread pain as the dominant symptom, along with fatigue, non-refreshed sleep, mood disturbance, and cognitive impairment, which significantly impact quality of life and emphasize its heterogeneous and complex nature. 1

Core Symptoms

Pain Characteristics

• Chronic widespread musculoskeletal pain affecting all four body quadrants
• Pain persisting for at least 3 months
• Pain often described as aching, burning, or throbbing
• Increased sensitivity to pressure at specific tender points
• Stiffness, particularly in the morning or after periods of inactivity

Associated Symptoms

• Fatigue: Persistent, often severe, not relieved by rest
• Sleep Disturbances: Non-refreshed sleep, insomnia, sleep apnea
• Cognitive Dysfunction ("fibro fog"):
  • Impaired concentration
  • Memory problems
  • Difficulty with mental clarity
• Mood Disorders:
  • Anxiety
  • Depression
  • Mood fluctuations

Diagnostic Considerations

Diagnosis is primarily clinical, based on:

1. Pattern of widespread pain affecting all four body quadrants
2. Multiple somatic symptoms
3. Absence of other conditions that would explain symptoms 1

The diagnosis often takes >2 years with an average of 3.7 consultations with different physicians 2, highlighting the importance of early recognition of the symptom pattern.

Treatment Approaches

Non-Pharmacological Management (First-Line)

• Exercise: The only "strong for" therapy recommendation based on meta-analyses 2

  • Individually tailored programs including aerobic exercise and strength training
  • Heated pool treatment with or without exercise

• Cognitive Behavioral Therapy: Beneficial for mood disorders and unhelpful coping strategies

• Education: Patient education about the condition is essential for management

Pharmacological Management (For Specific Symptoms)

For severe pain or sleep disturbance, consider:

• Antidepressants: Particularly SNRIs and tricyclics 1

  • Amitriptyline, fluoxetine, duloxetine, milnacipran (Level Ib, Strength A) 2

• Anticonvulsants:

  • Pregabalin: Effective for pain management (Level Ib, Strength A) 2, 3

• Analgesics:

  • Tramadol (Level Ib, Strength A) 2
  • Simple analgesics like paracetamol may be considered
  • Strong opioids are not recommended 2

Clinical Pitfalls and Caveats

1. Diagnostic Challenges: No specific diagnostic biomarkers exist; diagnosis relies on clinical criteria and exclusion of other conditions

2. Treatment Expectations: The size of effect for most treatments is relatively modest 2

3. Medication Side Effects: Be aware of potential adverse effects, particularly with medications like cyclobenzaprine where 85% of patients experience side effects 2

4. Comorbidities: Fibromyalgia often coexists with other conditions that may complicate diagnosis and treatment

5. Subtype Recognition: Different fibromyalgia subtypes exist (pain-predominant, fatigue-predominant, cognitive-predominant, and mood-predominant) 1, which may influence treatment selection

The most recent evidence supports a graduated approach to management, starting with patient education and non-pharmacological therapies, particularly exercise. Pharmacological interventions should be added for specific symptoms when non-pharmacological approaches are insufficient, with exercise remaining the cornerstone of effective management.