What is the first line of treatment for headaches in patients with fibromyalgia?

First-Line Treatment for Headaches in Fibromyalgia Patients

Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for headaches in patients with fibromyalgia, with aspirin, ibuprofen, naproxen sodium, and diclofenac potassium showing the strongest evidence for efficacy. 1

Understanding Headaches in Fibromyalgia

Headaches are extremely common in fibromyalgia patients, with studies showing:

• 76% of fibromyalgia patients report chronic headaches 2
• 55.8% of fibromyalgia patients meet criteria for migraine headaches 3
• Migraine is diagnosed in 63% of fibromyalgia patients with headache 2

Patients with both conditions typically experience:

• Higher headache frequency
• Poor sleep quality
• Increased pericranial tenderness
• Higher levels of anxiety
• Reduced physical performance 4

Treatment Algorithm for Headaches in Fibromyalgia

First-Line Treatment:

• NSAIDs: Start with aspirin, ibuprofen, naproxen sodium, or diclofenac potassium 1
• Paracetamol (acetaminophen) alone is less effective and should only be used in patients who cannot tolerate NSAIDs 1

Second-Line Treatment (if NSAIDs fail):

• Triptans: Consider when NSAIDs provide inadequate relief 1
  • Most effective when taken early in an attack while headache is still mild
  • If one triptan fails, others may still provide relief
  • Subcutaneous sumatriptan may be useful for patients who rapidly reach peak headache intensity or cannot take oral medications due to vomiting

Third-Line Treatment (if triptans fail or are contraindicated):

• Tramadol: Recommended for pain management in fibromyalgia with Level Ib, Strength A evidence 1, 5
• Antidepressants: Particularly effective for fibromyalgia patients with headaches
  • Amitriptyline, fluoxetine, duloxetine, and milnacipran (Level Ib, Strength A recommendation) 1, 5
• Anticonvulsants: Pregabalin for pain management (Level Ib, Strength A recommendation) 5

Important Considerations

Route of Administration:

• Select non-oral routes when nausea or vomiting is a significant component of headaches 1
• Consider treating nausea with an antiemetic medication

Medication Overuse Risk:

• Limit acute treatments to no more than twice a week to prevent medication-overuse headaches 1
• Consider preventive therapy if medication overuse is suspected or at risk

Preventive Treatment Indications:

• Two or more headache attacks per month with disability lasting 3+ days per month
• Use of rescue medication more than twice a week
• Failure of or contraindications to acute treatments 1

Complementary Approaches

For fibromyalgia patients with headaches, consider adding:

• Heated pool treatment with or without exercise (Level IIa, Strength B) 1, 5
• Individually tailored exercise programs including aerobic exercise and strength training (Level IIb, Strength C) 1, 5
• Cognitive behavioral therapy (Level IV, Strength D) 1, 5

Cautions

• Strong opioids are not recommended for fibromyalgia 1, 5
• Monitor for medication overuse, which can lead to rebound headaches
• Be aware that patients with both fibromyalgia and headaches often have higher rates of comorbidities including depression, anxiety, irritable bowel syndrome, and chronic fatigue syndrome 3