What are the treatment options for fibromyalgia?

Treatment Options for Fibromyalgia

The most effective first-line treatment for fibromyalgia is non-pharmacological therapy, particularly exercise therapy, which has the strongest evidence base for improving global well-being and physical function in fibromyalgia patients. 1

First-Line Non-Pharmacological Treatments

Exercise Therapy

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

Cognitive Behavioral Therapy (CBT)

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

Additional Non-Pharmacological Options

• Mindfulness-based stress reduction and relaxation techniques 1
• Meditative movement (yoga, tai chi, qigong) 1
• Heated pool treatment/hydrotherapy 1
• Dietary recommendations: Mediterranean-style diet emphasizing vegetables, fruits, whole grains, nuts, seeds, olive oil, moderate amounts of low-fat dairy and fish 1

First-Line Pharmacological Treatments

When non-pharmacological approaches provide insufficient relief, consider adding medication:

FDA-Approved Medications

1. Pregabalin (Lyrica)

   • Dosage: 300-450 mg/day (divided doses)
   • Efficacy: 68.1% of patients on 300 mg/day and 77.8% on 450 mg/day showed improvement vs. 47.6% on placebo 3
   • No evidence of greater effect with 600 mg/day than 450 mg/day, but increased adverse effects 3

2. Duloxetine (Cymbalta)

   • Dosage: 60 mg once daily
   • Efficacy: Significantly improved pain scores compared to placebo in fibromyalgia patients 4
   • Higher dosage (120 mg) showed no additional benefit but more adverse effects 4

3. Milnacipran

   • Particularly useful when fibromyalgia is comorbid with depression or anxiety 1

Second-Line Pharmacological Treatments

• Amitriptyline: 10-25 mg at bedtime for pain and sleep disorders (use with caution in older adults) 1
• Cyclobenzaprine: For pain and sleep disturbances 1
• Tramadol: For severe pain, but use cautiously due to risk of dependence 1

Treatments Not Recommended

• NSAIDs and strong opioids: Lack of efficacy and potential for harm 1
• Corticosteroids: Not effective and potential for adverse effects 1
• Cannabis: Should only be considered when conventional treatments have failed 1

Treatment Algorithm

1. Start with non-pharmacological approaches:

   • Prescribe regular exercise (aerobic and strengthening)
   • Refer for CBT if available
   • Educate on sleep hygiene and stress management techniques

2. If inadequate response after 4-6 weeks, add pharmacological therapy:

   • For predominant pain and sleep issues: Start pregabalin 75 mg twice daily, titrate to 150 mg twice daily as needed
   • For pain with comorbid depression/anxiety: Start duloxetine 30 mg daily for one week, then increase to 60 mg daily

3. Reassess after 4-6 weeks:

   • If partial response: Consider dose optimization or adding a second medication with a different mechanism
   • If no response: Switch to alternative first-line medication

4. For refractory cases:

   • Consider referral to multidisciplinary pain management program
   • Consider second-line medications like amitriptyline or tramadol

Special Considerations

• Pregnant patients: Focus on non-pharmacological approaches 1
• Elderly patients: Use lower initial doses with gradual titration 1
• Comorbid conditions: Address fibromyalgia symptoms separately while continuing treatment for other conditions 1

Monitoring and Follow-up

• Regular follow-up appointments (every 2-4 weeks initially)
• Monitor treatment response, medication side effects, sleep quality, and fatigue levels
• Assess adherence to exercise program and need for additional interventions

The multidimensional nature of fibromyalgia often requires combining treatments to address different symptom clusters. Recent evidence shows that tailoring treatment to predominant symptoms yields better outcomes than a one-size-fits-all approach 2.