What are the treatment options for fibromyalgia?

Treatment Options for Fibromyalgia

The management of fibromyalgia should follow a graduated approach starting with non-pharmacological therapies, particularly aerobic and strengthening exercise, followed by pharmacological options tailored to specific symptoms when needed. 1

Non-Pharmacological Treatments (First-Line)

Exercise Therapy

• Aerobic and strengthening exercise is the only treatment with a "strong for" recommendation (evidence level Ia) and should be the cornerstone of fibromyalgia management 1, 2
• Individually tailored exercise programs that include both aerobic components and strength training provide the most benefit for reducing pain and improving function 2
• Exercise benefits can be observed as early as week 1 and persist throughout treatment 3

Other Non-Pharmacological Approaches

• Cognitive behavioral therapy (CBT) has strong evidence (level Ia) and is particularly beneficial for patients with mood disorders and unhelpful coping strategies 1, 2
• Multicomponent therapies combining different treatment modalities show good evidence (level Ia) for improving symptoms 1
• Physical therapies such as acupuncture and hydrotherapy have demonstrated efficacy (level Ia) 1, 2
• Meditative movement therapies (qigong, yoga, tai chi) and mindfulness-based stress reduction can be beneficial (level Ia) 1

Pharmacological Treatments (Second-Line)

First-Choice Medications

• Amitriptyline at low doses (10-75 mg/day) has strong evidence (level Ia) for pain reduction and improved function 1, 2
• Duloxetine and milnacipran (SNRIs) have strong evidence (level Ia) for pain reduction and often improve function 2, 4
• Pregabalin has strong evidence (level Ia) for pain reduction and is FDA-approved specifically for fibromyalgia 1, 3
• Clinical trials show that some patients experience pain reduction as early as week 1 with pregabalin, which persists throughout treatment 3

Second-Choice Medications

• Tramadol has good evidence (level Ib) for pain management, particularly when other medications are ineffective 1, 2
• Cyclobenzaprine has moderate evidence (level Ia) and may be particularly helpful for patients with significant muscle spasm 1

Treatment Algorithm

1. Initial Approach:

   • Begin with patient education about fibromyalgia 1
   • Implement aerobic and strengthening exercise as the foundation of treatment 1, 2
   • Consider adding CBT if psychological symptoms are prominent 1

2. If Inadequate Response:

   • Add physical therapies such as acupuncture or hydrotherapy 1, 2
   • Consider meditative movement therapies or mindfulness-based stress reduction 1

3. For Persistent Symptoms:

   • Add pharmacological therapy based on predominant symptoms:
     • For pain and sleep disturbance: Amitriptyline (low dose) or pregabalin 1, 2
     • For pain and depression/anxiety: Duloxetine or milnacipran 2, 4
     • For significant muscle pain/spasm: Cyclobenzaprine 1
     • For severe pain unresponsive to above: Consider tramadol 1, 2

4. For Refractory Cases:

   • Consider multicomponent rehabilitation programs that combine multiple therapeutic approaches 5, 6

Important Considerations and Pitfalls

• Avoid strong opioids and corticosteroids as they are not recommended for fibromyalgia treatment 2
• Higher doses of medications do not necessarily provide better outcomes but may increase adverse effects (e.g., with pregabalin, 450mg daily was as effective as 600mg daily but with fewer side effects) 3
• The effect size for most pharmacological treatments is relatively modest, highlighting the importance of combining approaches 1
• Regular reassessment is essential to evaluate treatment efficacy and adjust the approach as needed 2
• Treatment should be tailored according to pain intensity, function, associated features (depression, anxiety), fatigue, sleep disturbance, patient preferences, and comorbidities 1
• Multidisciplinary approaches that combine pharmacological and non-pharmacological treatments have shown better outcomes than single-modality approaches 7, 6

Research Gaps

• The optimal type and intensity of exercise (strength vs. aerobic) remains unclear 1
• The effectiveness of combined pharmacological and non-pharmacological approaches compared to single-modality management needs further study 1
• Better understanding of patient characteristics that predict response to specific therapies would help personalize treatment 1