What is the treatment for fibromyalgia?

Treatment of Fibromyalgia

A step-wise approach to fibromyalgia treatment should begin with non-pharmacological therapies (especially exercise) as first-line treatment, followed by targeted pharmacological therapies based on predominant symptoms. 1

Non-Pharmacological Therapies (First-Line)

Exercise Therapy

• Aerobic exercise and strength training: 2-3 sessions per week, 10-30 minutes per session, starting with low intensity and gradually increasing 1
• Different exercise types target different symptoms:
  • All exercise forms improve pain and depression (except flexibility exercises)
  • Mind-body and strengthening exercises improve fatigue
  • Aerobic and strengthening exercises improve sleep 2

Other Non-Pharmacological Approaches

• Heated pool treatment/hydrotherapy: Shows significant benefits 1
• Cognitive Behavioral Therapy (CBT): 8-12 weekly sessions to address pain catastrophizing and improve coping strategies 1
• Mindfulness-based stress reduction: Helps with pain, sleep, and depression 1, 2
• Mediterranean-style diet: Emphasizing vegetables, fruits, whole grains, nuts, seeds, olive oil, moderate amounts of low-fat dairy and fish, while limiting added sugars and processed foods 1

Pharmacological Therapies (Add if Non-Pharmacological Approaches Insufficient)

First-Line Medications

• Amitriptyline: Starting dose 10-25 mg at bedtime for pain and sleep disturbances 1
• Pregabalin: Starting dose 75 mg twice daily for pain and sleep disturbances 1, 3
• Duloxetine: Starting dose 30-60 mg daily, especially beneficial for patients with comorbid depression or anxiety 1, 4
• Milnacipran: 100 mg/day (FDA-approved specifically for fibromyalgia) 3, 4

Second-Line Medications

• Tramadol: For severe pain, but use cautiously due to risk of dependence 1
• Cyclobenzaprine: For pain and sleep disturbances 1

Treatment Algorithm

1. Initial Approach:

   • Confirm diagnosis using ACR criteria
   • Identify predominant symptoms (pain, fatigue, sleep disturbance, depression)
   • Begin patient education about fibromyalgia management
   • Initiate aerobic and strengthening exercise program

2. If response is insufficient after 4-8 weeks:

   • Add CBT, mindfulness, hydrotherapy, or other non-pharmacological approaches

3. Add pharmacological therapy based on predominant symptoms:

   • For pain and sleep disturbances: Amitriptyline or pregabalin
   • For pain with depression/anxiety: Duloxetine or milnacipran
   • For severe pain unresponsive to above: Consider tramadol (cautiously)

4. Reassess every 4-8 weeks:

   • A 30% reduction in symptoms is considered clinically significant
   • Adjust therapy based on response and side effects

Important Considerations and Pitfalls

• Avoid ineffective treatments:

  • NSAIDs and strong opioids are not recommended due to lack of efficacy and potential harm 1, 4
  • Corticosteroids are not recommended 1

• Set realistic expectations:

  • Treatments typically provide modest benefits rather than complete resolution 1
  • Multimodal therapy is usually required; no single treatment addresses all symptoms 5, 6

• Special populations:

  • Pregnant patients: Focus on non-pharmacological approaches 1
  • Elderly patients: Use lower initial doses of medications with gradual titration 1
  • Patients with comorbid conditions: Address fibromyalgia symptoms separately while continuing treatment for other conditions 1

• Medication considerations:

  • Start with low doses and gradually increase to minimize side effects 5
  • FDA-approved medications include duloxetine, milnacipran, and pregabalin (in the US) 5, 4
  • Treatment with milnacipran 200 mg/day does not confer greater benefit than 100 mg/day 3

By following this structured approach and individualizing treatment based on predominant symptoms, patients with fibromyalgia can experience significant improvement in pain, function, and quality of life.