What is the best treatment for fibromyalgia?

Best Treatment for Fibromyalgia

The best treatment for fibromyalgia is a combination of non-pharmacological therapies (particularly aerobic and strengthening exercise, cognitive-behavioral therapy) as first-line approach, followed by FDA-approved medications (duloxetine, milnacipran, or pregabalin) when needed, based on predominant symptoms. 1

First-Line Treatment: Non-Pharmacological Approaches

Exercise Therapy (Strongest Evidence)

• Aerobic and strengthening exercise (2-3 sessions/week, 10-30 minutes per session)
  • Start with low intensity and gradually increase
  • Significantly improves pain (effect size -0.72 to -0.96) and depression (effect size -0.35 to -1.22) 1, 2
  • Strengthening exercises specifically improve sleep (effect size -0.74 to -1.33) 2
  • Mind-body exercises improve fatigue (effect size -0.77 to -1.00) 2

Cognitive Behavioral Therapy (CBT)

• Typically consists of 8-12 weekly sessions
• Addresses pain catastrophizing and improves coping strategies
• Effectively improves pain, sleep, and depression (effect size -0.35 to -0.55) 1, 2

Additional Non-Pharmacological Options

• Heated pool treatment/hydrotherapy - Level IIa, B recommendation 1
• Mindfulness-based stress reduction and meditative movement (yoga, tai chi, qigong) 1
• Mediterranean-style diet - emphasizing vegetables, fruits, whole grains, nuts, seeds, olive oil, and including moderate amounts of low-fat dairy and fish 1

Second-Line Treatment: Pharmacological Approaches

FDA-Approved Medications

Select based on predominant symptoms:

1. For pain with sleep disorders:

   • Pregabalin (75 mg twice daily) 1, 3
   • Amitriptyline (10-25 mg at bedtime) - use with caution in older adults 1

2. For pain with depression/anxiety:

   • Milnacipran (100 mg/day) - FDA-approved specifically for fibromyalgia 1, 3
   • Duloxetine - FDA-approved for fibromyalgia 1, 4

Other Medication Options

• Cyclobenzaprine may be considered for pain and sleep disturbances (weak recommendation) 1
• Tramadol may be considered for severe pain (weak recommendation) - use cautiously due to risk of dependence 1

Medications to Avoid

• NSAIDs - not recommended due to lack of efficacy 1, 5
• Strong opioids - not recommended due to potential for harm 1
• Corticosteroids - not recommended due to lack of efficacy and potential for harm 1
• Cannabis - not recommended as first-line treatment due to limited evidence, lack of standardization, and potential adverse effects 1

Treatment Algorithm

1. Start with non-pharmacological therapies:

   • Prescribe aerobic and strengthening exercise program
   • Refer for CBT if available
   • Educate patient about condition and self-management strategies

2. If inadequate response after 4-6 weeks, add pharmacological therapy based on predominant symptoms:

   • Pain + sleep disturbance → Pregabalin or low-dose amitriptyline
   • Pain + depression/anxiety → Milnacipran or duloxetine
   • Pain + fatigue → Milnacipran

3. If inadequate response after 4-6 weeks of medication:

   • Consider switching to another first-line medication
   • Consider combination therapy (e.g., pregabalin + milnacipran)
   • For severe refractory pain, consider adding tramadol (with caution)

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

Common Pitfalls to Avoid

1. Overreliance on medications - Non-pharmacological approaches should be the foundation of treatment 1, 6
2. Using ineffective medications - NSAIDs and opioids have poor evidence for fibromyalgia 1, 5
3. Inadequate dose or duration - Start with low doses and gradually increase to minimize side effects 5
4. Focusing on single symptoms - Address the constellation of symptoms (pain, fatigue, sleep, mood) 4, 7
5. Neglecting patient education - Understanding the condition is crucial for self-management 1