What are the treatment options for fibromyalgia?

Treatment for Fibromyalgia

Optimal treatment for fibromyalgia requires a multidisciplinary approach combining non-pharmacological and pharmacological therapies tailored to the patient's pain intensity, function, and associated symptoms such as depression, fatigue, and sleep disturbance. 1

Non-Pharmacological Management

• Heated pool treatment with or without exercise is effective for fibromyalgia with level of evidence IIa, strength B. 1

• Individually tailored exercise programs including aerobic exercise and strength training are beneficial with level of evidence IIb, strength C. 1, 2

• Cognitive behavioral therapy (CBT) may benefit patients, particularly those with mood disorders, with level of evidence IV, strength D. 1, 3, 2

• Additional supportive therapies such as relaxation, rehabilitation, physiotherapy, and psychological support should be used based on individual patient needs with level of evidence IIb, strength C. 1

Pharmacological Management

First-Line Medications

• Amitriptyline (10-75 mg/day) is recommended with level of evidence Ib, strength A for pain reduction and improved function. It should be considered first-line despite limited quality data on long-term efficacy. 1, 4, 5

• Duloxetine and milnacipran (SNRIs) are recommended with level of evidence Ib, strength A for pain reduction and often improve function. 1, 6, 2

• Pregabalin reduces pain with level of evidence Ib, strength A and is FDA-approved for fibromyalgia. Studies show significant pain reduction compared to placebo. 1, 7, 8

Second-Line Medications

• Tramadol is recommended for pain management with level of evidence Ib, strength A, particularly when other medications are ineffective. 1, 3

• Simple analgesics such as paracetamol (acetaminophen) and other weak opioids can be considered, though evidence is limited. 1, 3

Medications to Avoid

• Corticosteroids and strong opioids are not recommended for fibromyalgia treatment. 1, 3, 2

• NSAIDs have not demonstrated significant benefits for fibromyalgia and have potential side effects. 2, 8

Treatment Algorithm

1. Initial approach: Begin with patient education about the condition and start non-pharmacological therapies:

   • Heated pool therapy and/or individually tailored exercise program 1
   • Consider CBT if psychological factors are prominent 1, 2

2. First-line pharmacological therapy:

   • Low-dose amitriptyline (starting at 10-25 mg at bedtime) 4, 9, 5
   • OR pregabalin (starting at 75 mg twice daily) if sleep disturbance is prominent 7, 8
   • OR duloxetine (60 mg daily) if comorbid depression exists 6, 2

3. Inadequate response to initial therapy:

   • Switch to or add another first-line agent 1, 2
   • Consider tramadol for additional pain relief 1

4. Maintenance therapy:

   • Continue effective medications at the lowest effective dose 9
   • Maintain non-pharmacological approaches indefinitely 1, 8

Important Considerations

• Medication adherence is challenging - studies show only about 20% of patients continue treatment for ≥1 year. 9

• Start low, go slow - Begin medications at lower doses and titrate slowly to minimize side effects. Most patients remain on the same dose throughout treatment. 9, 5

• Manage expectations - The effect of most treatments is relatively modest; complete pain relief is uncommon. 5

• Monitor for side effects - Particularly with tricyclic antidepressants and SNRIs, which commonly cause sedation, dry mouth, and constipation. 4, 9

• Regular reassessment is essential to evaluate treatment efficacy and adjust the approach as needed. 1