What are the diagnosis and treatment options for fibromyalgia?

Fibromyalgia Diagnosis and Treatment

The most effective approach to fibromyalgia management is to start with non-pharmacological therapies, particularly exercise therapy, while adding targeted medications based on predominant symptoms. 1

Diagnosis

The American College of Rheumatology (ACR) criteria for diagnosing fibromyalgia include:

• Widespread Pain Index (WPI): Assessment of pain in multiple body regions
• Symptom Severity Scale (SS): Evaluation of fatigue, unrefreshing sleep, and cognitive issues
• Tender point examination: Pain upon digital pressure in at least 11 of 18 tender points with approximately 4 kg of pressure 1

The Fibromyalgia Rapid Screening Tool can help identify patients with diffuse chronic pain who should be evaluated further 2.

Treatment Approach

First-Line Non-Pharmacological Therapies

1. Exercise Therapy (strongest evidence base):

   • 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 1

2. Cognitive Behavioral Therapy (CBT):

   • 8-12 weekly sessions
   • Addresses pain catastrophizing and improves coping strategies 1

3. Additional Non-Pharmacological Options:

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

Pharmacological Treatment

First-Line Medications:

1. Duloxetine (SNRI):

   • Particularly effective when fibromyalgia is comorbid with depression or anxiety
   • FDA-approved for fibromyalgia
   • Studies show significant pain reduction compared to placebo 3

2. Pregabalin:

   • FDA-approved for fibromyalgia
   • 75 mg twice daily for pain and sleep disorders
   • Demonstrated reduction in pain by visual analog scale and improvement on Fibromyalgia Impact Questionnaire 4

3. Amitriptyline:

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

4. Milnacipran (SNRI):

   • FDA-approved for fibromyalgia
   • Especially useful when comorbid with depression or anxiety 1

Second-Line Medications:

1. Tramadol:

   • For severe pain
   • Use cautiously due to risk of dependence 1

2. Cyclobenzaprine:

   • For pain and sleep disturbances 1

Treatments to Avoid

• NSAIDs: Not effective for fibromyalgia 1, 2
• Strong opioids: Not recommended due to lack of efficacy and potential for harm 1
• Corticosteroids: Not effective and may cause harm 1

Special Populations

1. Pregnant patients: Focus on non-pharmacological approaches 1
2. Elderly patients: Use lower initial medication doses with gradual titration 1
3. Patients with comorbid conditions: Address fibromyalgia symptoms separately while continuing treatment for other conditions 1

Follow-up and Monitoring

• Regular follow-up appointments (initially every 2-4 weeks)
• Monitor:
  • Treatment response
  • Medication side effects
  • Adherence to exercise program
  • Sleep quality
  • Fatigue levels 1

Common Pitfalls to Avoid

1. Overreliance on medications: Non-pharmacological therapies should be the foundation of treatment
2. Inadequate patient education: Understanding the condition is crucial for patient engagement
3. Failure to address sleep disturbances: Poor sleep worsens pain and fatigue
4. Inappropriate use of opioids: These can worsen symptoms long-term
5. Neglecting psychological aspects: Depression and anxiety often coexist with fibromyalgia and require treatment

The heterogeneity of fibromyalgia requires a comprehensive approach that addresses the wide spectrum of symptoms. While there is no cure, timely recognition and appropriate treatment can significantly improve quality of life 5.