What is the recommended treatment for fibromyalgia?

Fibromyalgia Treatment

The recommended first-line treatment for fibromyalgia is a combination of non-pharmacological approaches, particularly aerobic and strengthening exercise, with pharmacological therapy tailored to predominant symptoms. 1

Non-Pharmacological Approaches (First-Line)

Exercise Therapy

• Aerobic and strengthening exercise has the strongest evidence (Level Ia, Grade A) and should be implemented as the cornerstone of treatment 2
• Begin with low-impact activities and gradually increase intensity
• Individually tailored exercise programs are most effective for pain reduction and functional improvement
• Pool-based therapy may provide additional benefits for some patients 1

Cognitive Behavioral Therapy (CBT)

• Strong evidence supports CBT as an effective treatment (Level Ia, Grade A) 2
• Helps patients develop coping strategies for pain management
• Addresses negative thought patterns that may amplify pain perception

Additional Non-Pharmacological Options

• Multicomponent therapies (weak recommendation, 93% agreement) 2
• Meditative movement therapies like yoga, tai chi, and qigong (weak recommendation) 1
• Acupuncture or hydrotherapy (weak recommendation, 93% agreement) 2

Pharmacological Management

First-Line Medications

1. Amitriptyline (weak recommendation, 100% agreement) 2

   • Start with low dose (10-25mg at bedtime)
   • Effective for pain, sleep disturbance, and fatigue
   • Take advantage of sedative effects by administering at night 1

2. Duloxetine or Milnacipran (weak recommendation, 100% agreement) 2

   • Particularly effective when pain is accompanied by depression or fatigue
   • Effective dosage for duloxetine is 60mg daily 1
   • Monitor for side effects including blood pressure changes, nausea

3. Pregabalin (weak recommendation, 94% agreement) 2

   • FDA-approved specifically for fibromyalgia 3
   • Recommended dose is 300-450mg/day 3
   • Begin at 75mg twice daily and titrate based on response 3
   • Particularly helpful for pain and sleep disturbance

Second-Line Medications

1. Tramadol (weak recommendation, 100% agreement) 2

   • Can be considered for pain management
   • Use cautiously due to potential for dependence

2. Cyclobenzaprine (weak recommendation, 75% agreement) 2

   • Muscle relaxant that may help with pain and sleep disturbance

Treatment Algorithm

1. Start with non-pharmacological approaches:

   • Prescribed exercise program (aerobic and strengthening)
   • Cognitive behavioral therapy
   • Patient education about the condition

2. Add pharmacological therapy based on predominant symptoms:

   • Pain + sleep disturbance → Amitriptyline or pregabalin
   • Pain + depression → Duloxetine
   • Pain + fatigue → Duloxetine or milnacipran

3. If inadequate response after 4-6 weeks:

   • Adjust medication dosage within recommended ranges
   • Consider switching to a different medication class
   • For pregabalin, may increase to 450mg/day if 300mg/day provides insufficient benefit 3

4. For refractory cases:

   • Consider combination therapy (e.g., pregabalin + duloxetine) which has shown superior efficacy compared to monotherapy 4
   • Add tramadol for additional pain relief if needed

Important Considerations and Cautions

• Avoid strong opioids and corticosteroids as they are not recommended for fibromyalgia management 2, 1
• Start medications at low doses and titrate gradually to minimize side effects 1
• Monitor for side effects, particularly sedation, dizziness, and cognitive effects
• Pregabalin dosage should not exceed 450mg/day as higher doses increase adverse effects without additional benefit 3
• Only about 20% of patients continue their initial medication for ≥1 year, highlighting the need for ongoing assessment and adjustment 5
• Combination therapy with pregabalin and duloxetine may be more effective than either medication alone for improving pain, function, and quality of life 4

Follow-up and Monitoring

• Regular assessment of treatment response using validated tools
• Periodic reevaluation of medication necessity and dosage
• Encourage continued adherence to non-pharmacological approaches
• Adjust treatment plan based on changing symptom patterns

By following this evidence-based approach that prioritizes non-pharmacological interventions alongside targeted medication therapy, most patients with fibromyalgia can achieve meaningful improvement in pain, function, and quality of life.