What treatment options are available for a patient with fibromyalgia?

Treatment Options for Fibromyalgia

For patients with fibromyalgia, a combination of non-pharmacological approaches (particularly exercise) should be initiated first, followed by pharmacological options including amitriptyline, duloxetine, milnacipran, or pregabalin if needed, based on symptom profile and patient characteristics. 1

Non-Pharmacological Management (First-Line)

• Aerobic and strengthening exercise is strongly recommended as the primary non-pharmacological intervention with the highest level of evidence (Ia, A) 1
• Cognitive behavioral therapy is recommended particularly for patients with concurrent mood disorders (Ia, A) 1
• Multicomponent therapies that combine different approaches show benefit (Ia, A) 1
• Specific physical therapies including acupuncture and hydrotherapy/heated pool treatment are beneficial (Ia, A) 1
• Meditative movement therapies (qigong, yoga, tai chi) and mindfulness-based stress reduction can be helpful (Ia, A) 1

Pharmacological Management

First-Line Medications

• Amitriptyline at low doses (10-75 mg/day) is recommended for pain reduction and improved function (Ia, A) 1, 2

  • Benefits include improved sleep and pain reduction
  • Note: Tricyclic antidepressants may be inappropriate for older adults (≥65 years) due to anticholinergic effects 1

• Duloxetine or milnacipran (SNRIs) are recommended for pain reduction and functional improvement (Ia, A) 1, 2

  • FDA-approved specifically for fibromyalgia 3
  • Common side effects of milnacipran include nausea, constipation, hot flush, hyperhidrosis, and palpitations 4

• Pregabalin is recommended for pain reduction (Ia, A) 1, 2

  • FDA-approved for fibromyalgia 1, 3
  • Common side effects include dizziness, somnolence, weight gain, peripheral edema, and blurred vision 5
  • Effective for moderate to severe pain in fibromyalgia, though only benefits a minority of patients 6

Second-Line Medications

• Cyclobenzaprine can be considered for pain management (Ia, A) 1

• Tramadol is recommended for pain management (Ib, A) when other medications are ineffective 1, 2

  • Use with caution due to risk of dependence and side effects

Medications to Avoid

• Corticosteroids are not recommended for fibromyalgia treatment 1, 2
• Strong opioids are not recommended and have not demonstrated benefits for fibromyalgia 1, 3
• NSAIDs have limited evidence for effectiveness in fibromyalgia 3

Treatment Algorithm

1. Initial approach:

   • Begin with patient education about fibromyalgia 1, 2
   • Start with aerobic and strengthening exercise as the foundation of treatment 1
   • Consider adding cognitive behavioral therapy, especially with concurrent mood disorders 1, 2

2. If insufficient response to non-pharmacological approaches:

   • Add pharmacological therapy based on predominant symptoms:
     • For pain with sleep disturbance: Amitriptyline (low dose) or pregabalin 2, 3
     • For pain with depression/anxiety: Duloxetine 2, 3
     • For pain with fatigue: Milnacipran 7

3. If inadequate response to first medication:

   • Consider switching to another first-line medication or combining medications from different classes 7, 8
   • Add tramadol for severe pain not responding to other treatments 1, 2

Important Considerations

• Treatment adherence is often poor - only about 20% of patients continue treatment for ≥1 year 9
• Most patients remain on the same medication dose throughout treatment 9
• Treatment effects for all medications are generally modest, with small to moderate improvements in pain, function, and quality of life 7, 8
• Combination therapy (using multiple medication classes or combining pharmacological with non-pharmacological approaches) may be more effective than monotherapy but requires further research 7, 8