What are the recommended diagnosis and management strategies for fibromyalgia?

Fibromyalgia Diagnosis and Management

Exercise therapy, cognitive behavioral therapy, and patient education should be the first-line treatments for fibromyalgia, with medications like pregabalin, duloxetine, milnacipran, or amitriptyline added for symptom management when necessary. 1

Diagnosis

Diagnostic Criteria

• American College of Rheumatology (ACR) Criteria:
  • History of widespread pain present for at least 3 months
  • Pain upon digital pressure in at least 11 of 18 tender points (approximately 4 kg pressure) 1
  • The 2010 updated ACR criteria no longer require tender point examination 2

Screening and Assessment

• Fibromyalgia Rapid Screening Tool is recommended for patients with diffuse chronic pain 2
• Diagnostic workup should be limited:
  • Extensive laboratory tests and imaging are not required 3
  • Focus on ruling out other conditions that may mimic fibromyalgia

Management Approach

First-Line: Non-Pharmacological Therapies

1. Exercise Therapy (strongest evidence base) 1

   • Aerobic exercise and strength training
   • 2-3 sessions/week, 10-30 minutes per session
   • Start with low intensity and gradually increase
   • Focus on improving function and reducing symptoms

2. Cognitive Behavioral Therapy (CBT) 1

   • Addresses pain catastrophizing
   • Improves coping strategies
   • Typically 8-12 weekly sessions

3. Patient Education 1, 2

   • Explain the nature of fibromyalgia as a centralized pain syndrome
   • Reassure that diagnosis is established and unnecessary testing can be avoided
   • Set realistic expectations for management

4. Additional Non-Pharmacological Options:

   • Heated pool treatment/hydrotherapy (Level IIa, B recommendation) 1
   • Mindfulness-based stress reduction 1
   • Meditative movement (yoga, tai chi, qigong) 1
   • Mediterranean-style diet 1

Second-Line: Pharmacological Therapies

Select medications based on predominant symptoms:

1. First-line medications (weak recommendation, level Ia evidence) 1:

   • Pregabalin (75 mg twice daily) - effective for pain and sleep disorders 1, 4

     • FDA approved for fibromyalgia at 300-450 mg/day 4
     • Begin at 75 mg twice daily, may increase to 150 mg twice daily within 1 week 4
     • Maximum 225 mg twice daily (450 mg/day) 4
     • Note: 600 mg/day shows no additional benefit but has more adverse effects 4

   • Duloxetine - especially when comorbid with depression or anxiety 1, 2

   • Milnacipran - especially when comorbid with depression or anxiety 1, 2

   • Amitriptyline (10-25 mg at bedtime) - effective for pain and sleep disorders 1, 2

     • Use with caution in older adults

2. Second-line medications:

   • Cyclobenzaprine - for pain and sleep disturbances (weak recommendation, level Ia evidence) 1
   • Tramadol - for severe pain (weak recommendation, level Ib evidence) 1
     • Use cautiously due to risk of dependence

3. NOT recommended:

   • NSAIDs - lack of efficacy 1, 2
   • Strong opioids - lack of efficacy and potential for harm 1, 2
   • Corticosteroids - lack of efficacy and potential for harm 1
   • Cannabis - limited and inconsistent evidence, not recommended as first-line treatment 1

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:
  • Continue disease-modifying treatments for inflammatory arthritis while addressing fibromyalgia symptoms separately 1
  • Address fibromyalgia symptoms separately while continuing treatment for other conditions 1

Monitoring and Follow-up

• Regular assessment of:
  • Adherence to exercise program
  • Symptom improvement
  • Need for additional interventions
  • Medication effectiveness and adverse effects 1

Common Pitfalls to Avoid

1. Overreliance on medications - Non-pharmacological therapies should be the foundation of treatment
2. Excessive testing - Once diagnosis is established, avoid unnecessary investigations
3. Prescribing opioids - These have not shown benefit and carry significant risks
4. Neglecting exercise therapy - The strongest evidence supports regular physical activity
5. Focusing only on pain - Address sleep, fatigue, and mood disturbances as part of comprehensive management

By implementing this evidence-based approach to fibromyalgia diagnosis and management, clinicians can help patients achieve improved function and quality of life while minimizing unnecessary treatments and potential harms.