What are the diagnostic criteria and treatment options for fibromyalgia?

Diagnosis and Treatment of Fibromyalgia

The diagnosis of fibromyalgia is based on the American College of Rheumatology (ACR) criteria, which include assessment of widespread pain index (WPI) and symptom severity (SS) scale, while treatment should start with non-pharmacological approaches such as exercise therapy, followed by FDA-approved medications like pregabalin, duloxetine, or milnacipran when necessary. 1

Diagnostic Criteria for Fibromyalgia

Fibromyalgia is characterized by chronic widespread musculoskeletal pain, fatigue, unrefreshing sleep, and cognitive issues that significantly impact quality of life. The diagnosis is clinical and based on the following criteria:

American College of Rheumatology (ACR) Criteria:

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

Important Diagnostic Considerations:

• Fibromyalgia is not a diagnosis of exclusion - positive identification of characteristic symptoms is required
• Laboratory tests are used primarily to rule out other conditions, not to confirm fibromyalgia
• The Fibromyalgia Rapid Screening Tool can be helpful for initial assessment of patients with diffuse chronic pain 2

Treatment Approach for Fibromyalgia

First-Line Non-Pharmacological Treatments:

• 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

• Cognitive Behavioral Therapy (CBT):

  • 8-12 weekly sessions to address pain catastrophizing and improve coping strategies 1

• Additional Non-Pharmacological Options:

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

First-Line Pharmacological Treatments:

1. Pregabalin (75 mg twice daily):

   • FDA-approved for fibromyalgia
   • Particularly effective for pain and sleep disorders 1, 3

2. Duloxetine (60 mg once daily):

   • FDA-approved for fibromyalgia
   • Particularly beneficial when comorbid with depression 1, 4

3. Milnacipran:

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

4. Amitriptyline (10-25 mg at bedtime):

   • For pain and sleep disorders
   • Use with caution in older adults 1

Second-Line Pharmacological Treatments:

• Tramadol for severe pain (use cautiously due to risk of dependence) 1
• Cyclobenzaprine for pain and sleep disturbances 1

Treatments to Avoid:

• NSAIDs and strong opioids are not recommended due to lack of efficacy and potential for harm 1
• Corticosteroids are not recommended due to lack of efficacy and potential for harm 1

Special Considerations

Patient 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: Address fibromyalgia symptoms separately while continuing treatment for other conditions 1

Monitoring and Follow-up:

• Regular follow-up appointments to assess:
  • Treatment response
  • Medication side effects
  • Adherence to exercise program
  • Symptom improvement
  • Need for additional interventions 1

Treatment Efficacy

• In clinical trials, pregabalin showed significant improvement in pain scores and patient global impression of change 3
• Duloxetine demonstrated statistically significant improvement in pain scores with benefits observed as early as week 1 4
• The heterogeneity of fibromyalgia symptoms requires a comprehensive approach that addresses pain, sleep disturbances, fatigue, and cognitive dysfunction 5

Common Pitfalls to Avoid

• Relying solely on tender points for diagnosis without considering the broader symptom profile
• Focusing only on pharmacological treatments without implementing exercise and behavioral therapies
• Prescribing opioids or NSAIDs as primary treatment
• Failing to address sleep disturbances, which can exacerbate pain symptoms
• Not providing adequate patient education about the chronic nature of the condition and realistic treatment expectations