What are the recommended treatments for fibromyalgia?

Fibromyalgia Treatment

The first-line treatment for fibromyalgia should be non-pharmacological therapies, particularly exercise therapy, which has the strongest evidence base for improving global well-being and physical function. 1

Non-Pharmacological Therapies

Exercise Therapy (First-Line)

• Recommended regimen: 2-3 sessions per week, 10-30 minutes per session 1
• Start with low intensity and gradually increase
• Focus on:
  • Aerobic exercise (improves pain and depression)
  • Strengthening exercises (improves pain, depression, fatigue, and sleep)
  • Mind-body exercises (improves fatigue)
• All forms of exercise except flexibility exercises alone have been shown to improve pain and depression 2

Cognitive Behavioral Therapy (CBT)

• Typically 8-12 weekly sessions 1
• Addresses pain catastrophizing and improves coping strategies
• Improves FIQ scores, pain, sleep, and depression but not fatigue 2

Additional Non-Pharmacological Options

• Heated pool treatment/hydrotherapy (Level IIa, B recommendation) 1
• Mindfulness-based stress reduction 1
• Relaxation techniques 1
• Meditative movement (yoga, tai chi, qigong) 1
• Mediterranean-style diet (emphasizing vegetables, fruits, whole grains, nuts, seeds, olive oil) 1

Pharmacological Therapies

First-Line Medications

1. Duloxetine (SNRI)

   • Dosing: Start at 30 mg daily for 1 week, then increase to 60 mg daily 3
   • Particularly useful when fibromyalgia is comorbid with depression or anxiety 1
   • No evidence that doses higher than 60 mg/day provide additional benefit 3

2. Milnacipran (SNRI)

   • Dosing: 100 mg/day (50 mg twice daily) 4
   • Effective for pain reduction with concurrent global improvement 4
   • Higher doses (200 mg/day) do not confer additional benefits 4

3. Pregabalin

   • Dosing: 75 mg twice daily 1
   • Particularly effective for pain and sleep disorders 1

4. Amitriptyline

   • Dosing: 10-25 mg at bedtime 1
   • Effective for pain and sleep disorders
   • Use with caution in older adults 1

Second-Line Medications

• Cyclobenzaprine: May be considered for pain and sleep disturbances (weak recommendation) 1
• Tramadol: May be considered for severe pain but use cautiously due to dependence risk (weak recommendation) 1

Not Recommended

• NSAIDs: Lack of efficacy for fibromyalgia 1, 5
• Strong opioids: Not effective and potential for harm 1, 5
• Corticosteroids: Lack of efficacy and potential for harm 1
• Cannabis: Limited and inconsistent evidence; not recommended as first-line treatment 1

Treatment Algorithm

1. Start with non-pharmacological approaches:

   • Prescribe regular exercise program (aerobic + strengthening)
   • Refer for CBT if available
   • Educate patient on 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 amitriptyline
   • Pain + depression/anxiety → Duloxetine or milnacipran
   • Pain + fatigue → Milnacipran

3. If inadequate response to first medication after 4-6 weeks at optimal dose:

   • Switch to alternative first-line medication OR
   • Consider combination therapy (e.g., SNRI + pregabalin)

4. For refractory symptoms:

   • Consider cyclobenzaprine for persistent sleep disturbance
   • Consider tramadol for severe pain (with caution)
   • Reassess non-pharmacological compliance and optimize

Special Considerations

• Elderly patients: Start medications at lower doses with gradual titration 1
• Pregnancy: Focus on non-pharmacological approaches 1
• Hepatic impairment: Avoid duloxetine in chronic liver disease 3
• Renal impairment: Use caution with duloxetine in severe renal impairment 3
• Comorbid conditions: Address fibromyalgia symptoms separately while continuing treatment for other conditions 1

Common Pitfalls to Avoid

• Overreliance on medications: Non-pharmacological therapies should remain the foundation of treatment
• Using ineffective treatments: Avoid NSAIDs and opioids which lack efficacy for fibromyalgia
• Inadequate dose titration: Start low but ensure adequate therapeutic trial at optimal doses
• Neglecting comorbidities: Address sleep disorders, depression, and anxiety which can exacerbate symptoms
• Abrupt discontinuation: Taper medications gradually to avoid withdrawal symptoms, particularly SNRIs 3

Remember that fibromyalgia is a chronic condition requiring ongoing management. Regular follow-up is essential to assess treatment effectiveness and make necessary adjustments to the treatment plan.