What are the symptoms and treatment options for fibromyalgia?

Fibromyalgia Symptoms and Treatment Options

Fibromyalgia is characterized by chronic widespread pain affecting all four body quadrants, along with fatigue, non-refreshed sleep, mood disturbance, and cognitive impairment, requiring a multimodal treatment approach with exercise as the strongest recommendation, supplemented by medications such as SNRIs, tricyclic antidepressants, and anticonvulsants for symptom management. 1

Symptoms and Clinical Presentation

Fibromyalgia presents with a constellation of symptoms:

Primary Symptoms

• Chronic widespread pain (dominant symptom affecting all four body quadrants) 1
• Fatigue (often severe and persistent) 1, 2
• Non-refreshed sleep/sleep disturbances 1, 2
• Cognitive dysfunction (often called "fibro fog") 1, 2
• Mood disturbances (anxiety, depression) 1
• Stiffness (significantly impacts physical functioning) 1

Symptom Categories

Fibromyalgia can be categorized into different predominant symptom patterns:

• Pain-predominant
• Fatigue-predominant
• Cognitive-predominant
• Mood-predominant 1

Associated Symptoms

• Multiple somatic symptoms 1
• Intestinal disorders 3
• Hyperalgesia (increased sensitivity to pain) 1

Diagnosis

Diagnosis is clinical and based on:

• Pattern of symptoms (chronic widespread pain affecting all four body quadrants)
• Multiple somatic symptoms
• Absence of other conditions that would explain the symptoms 1

The American College of Rheumatology criteria or the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks-American Pain Society Pain Taxonomy diagnostic criteria can be used to diagnose fibromyalgia 2.

Diagnostic challenges:

• Diagnosis often takes more than 2 years with an average of 3.7 consultations with different physicians 1
• No specific laboratory tests exist for fibromyalgia 4
• Symptoms often overlap with other central pain disorders (e.g., irritable bowel syndrome, chronic fatigue syndrome) 4

Treatment Options

Non-Pharmacological Approaches (First-Line)

• Exercise - strongest recommendation with "strong for" therapy rating based on meta-analyses 1

  • Individually tailored programs including aerobic exercise and strength training
  • Heated pool treatment with or without exercise
  • Both land-based and water-based exercises help reduce stiffness

• Cognitive behavioral therapy - can improve pain and function 2

• Patient education - establishing diagnosis and providing education can reassure patients and decrease unnecessary testing 2

Pharmacological Approaches

First-Line Medications

• Antidepressants (Level Ib, Strength A recommendation) 1

  • SNRIs (duloxetine, milnacipran) - effective for pain and improved functional status 1, 5
  • Tricyclic antidepressants (amitriptyline) - effective for severe pain or sleep disturbance 1

• Anticonvulsants (Level Ib, Strength A recommendation) 1

  • Pregabalin - effective for pain management 1, 6
    • FDA-approved for fibromyalgia with demonstrated efficacy in reducing pain 6
    • Some patients experience pain reduction as early as Week 1 6

Second-Line Medications

• Analgesics (Level Ib, Strength A recommendation) 1

  • Tramadol may be considered for pain management 1
  • Strong opioids are not recommended 1

• NSAIDs have not demonstrated benefits for fibromyalgia 2

Treatment Considerations

• The effect size for most treatments is relatively modest 1

• Medication side effects should be carefully considered:

  • 85% of patients experience side effects with medications like cyclobenzaprine 1
  • Higher dosages of medications like duloxetine (120mg vs 60mg) show no additional benefit but increased adverse reactions 5

• Fibromyalgia often coexists with other conditions that may complicate treatment 1

• Symptoms significantly impact physical functioning, social relationships, work productivity, and overall quality of life 1

Treatment Algorithm

1. Start with non-pharmacological approaches:

   • Individually tailored exercise program
   • Patient education about the condition
   • Cognitive behavioral therapy

2. Add pharmacological therapy for persistent symptoms:

   • For pain and fatigue: SNRIs (duloxetine 60mg daily or milnacipran)
   • For sleep disturbance: Low-dose tricyclic antidepressants (amitriptyline)
   • For neuropathic pain features: Pregabalin (300-450mg daily)

3. Monitor and adjust:

   • Evaluate response after 4-6 weeks
   • Consider combination therapy for inadequate response
   • Avoid opioids and focus on long-term functional improvement