What are the treatment options for fibromyalgia?

Treatment Options for Fibromyalgia

Aerobic and strengthening exercise is strongly recommended as the primary intervention for fibromyalgia, with the highest level of evidence (Ia, A) for improving pain, function, and quality of life. 1, 2

Non-Pharmacological Management (First-Line)

• Aerobic and strengthening exercise is the only treatment with a "strong for" recommendation and should be initiated as the cornerstone of fibromyalgia management 1, 2
• Cognitive behavioral therapy (CBT) is particularly beneficial for patients with concurrent mood disorders and unhelpful coping strategies 1, 2, 3
• Multicomponent therapies that combine different approaches show significant benefit for overall symptom management 1, 2, 4
• Specific physical therapies including acupuncture and hydrotherapy/heated pool treatment provide relief for many patients 1, 2, 3
• Meditative movement therapies (qigong, yoga, tai chi) and mindfulness-based stress reduction can help manage symptoms and improve quality of life 1, 2

Pharmacological Management (Second-Line)

First-Line Medications (if non-pharmacological approaches insufficient)

• Amitriptyline at low doses (10-75 mg/day) is recommended for pain reduction and improved function 1, 2, 5
• Duloxetine or milnacipran (SNRIs) are effective for pain reduction and functional improvement 1, 2, 6
• Pregabalin is effective for pain reduction and is FDA-approved for fibromyalgia 1, 2, 7
• Cyclobenzaprine can be considered for pain management and may help with sleep disturbances 1, 2

Second-Line Medications

• Tramadol is recommended for pain management when other medications are ineffective 1, 2

Medications to Avoid

• Strong opioids are not recommended as they have not demonstrated benefits for fibromyalgia 2
• Corticosteroids are not recommended for fibromyalgia treatment 2, 8

Graduated Treatment Algorithm

1. Initial Approach: Begin with patient education about fibromyalgia and implement aerobic and strengthening exercise program 1, 2

   • Start with low-intensity exercise and gradually increase based on tolerance
   • Aim for 2-3 sessions per week of moderate-intensity aerobic exercise
   • Include progressive resistance training 2 times per week

2. If insufficient response after 4-6 weeks: Add other non-pharmacological therapies 1, 2

   • Cognitive behavioral therapy for patients with mood disorders
   • Heated pool therapy/hydrotherapy
   • Acupuncture
   • Mindfulness-based stress reduction

3. If still inadequate response: Consider adding pharmacological therapy 1, 2

   • For predominant pain: Start with pregabalin (300-450 mg/day) or duloxetine (60 mg/day) 7, 6
   • For pain with sleep disturbance: Low-dose amitriptyline (10-25 mg at bedtime) 1, 2
   • For pain with fatigue: Duloxetine or milnacipran 2, 6

4. For severe or refractory symptoms: Consider multicomponent rehabilitation programs that combine exercise, psychological interventions, and education 1, 2, 4

Symptom-Specific Approaches

• For pain: All forms of exercise except flexibility exercises alone; pregabalin, duloxetine, amitriptyline 2, 3
• For fatigue: Mind-body and strengthening exercises; duloxetine or milnacipran 2, 3
• For sleep disturbances: Aerobic and strengthening exercises; amitriptyline, pregabalin 2, 3
• For depression: All forms of exercise; CBT; duloxetine 2, 3

Important Considerations

• The effect size for most treatments is relatively modest, with most showing small to moderate benefits 1, 9
• Regular reassessment is essential to evaluate treatment efficacy and adjust the approach as needed 1, 2
• Combination of non-pharmacological and pharmacological approaches may be more effective than either alone, though more research is needed 1, 10
• Patient education about the nature of fibromyalgia as a chronic condition with central sensitization is crucial for setting realistic expectations 1