How to manage fibromyalgia?

Management of Fibromyalgia

The optimal management of fibromyalgia requires a graduated approach that begins with non-pharmacological therapies, particularly aerobic and strengthening exercise, followed by pharmacological interventions when necessary to improve health-related quality of life. 1, 2

Initial Assessment and Diagnosis

• Fibromyalgia requires comprehensive assessment of pain, function, and psychosocial context, recognizing it as a complex condition with abnormal pain processing 1
• Prompt diagnosis and patient education about the condition are essential first steps in management 1, 2

Non-Pharmacological Management (First-Line)

Exercise Therapy

• Aerobic and strengthening exercise has the strongest evidence (Level Ia, Grade A) and should be the primary non-pharmacological intervention 1, 2
• Exercise programs should be individually tailored and gradually increased in intensity based on patient tolerance 2

Cognitive Behavioral Therapy

• Cognitive behavioral therapy (CBT) is recommended particularly for patients with concurrent mood disorders (Level Ia, Grade A) 1, 2
• CBT helps address unhelpful coping strategies and psychological aspects of pain 2

Physical Therapies

• Acupuncture and hydrotherapy/heated pool treatment are beneficial (Level Ia, Grade A) 1, 2
• These therapies can provide symptomatic relief and improve function 2

Other Non-Pharmacological Approaches

• Multicomponent therapies that combine different approaches show benefit (Level Ia, Grade A) 1, 2
• Meditative movement therapies (qigong, yoga, tai chi) and mindfulness-based stress reduction can be helpful (Level Ia, Grade A) 1, 2

Pharmacological Management (Second-Line)

First-Line Medications

• Amitriptyline at low doses (10-75 mg/day) is recommended for pain reduction and improved function (Level Ia, Grade A) 1, 2
• Duloxetine or milnacipran (SNRIs) are effective for pain reduction and functional improvement (Level Ia, Grade A) 1, 2, 3
• Pregabalin is effective for pain reduction and is FDA-approved for fibromyalgia (Level Ia, Grade A) 1, 2, 4

Second-Line Medications

• Cyclobenzaprine can be considered for pain management (Level Ia, Grade A) 1
• Tramadol is recommended for pain management (Level Ib, Grade A) when other medications are ineffective 1, 2

Medications to Avoid

• Corticosteroids are not recommended for fibromyalgia treatment 2
• Strong opioids are not recommended as they have not demonstrated benefits for fibromyalgia 2, 5
• NSAIDs have not demonstrated significant benefits for fibromyalgia 5

Treatment Algorithm

1. Initial Approach:

   • Begin with patient education about fibromyalgia 1, 2
   • Implement aerobic and strengthening exercise program with gradual intensity increase 1, 2

2. If insufficient response after 4-6 weeks:

   • Add other non-pharmacological therapies (CBT, hydrotherapy, acupuncture, mindfulness) 2

3. If still inadequate response:

   • Start with low-dose amitriptyline (10-25 mg at bedtime) 1, 2, 6
   • Alternative first medications include pregabalin or duloxetine/milnacipran 1, 2

4. For inadequate response to initial medication:

   • Try an alternative medication from a different class 2, 7
   • Consider combination therapy targeting different mechanisms 7

Important Considerations

• The effect size for most treatments is relatively modest, with small to moderate benefits 2
• Regular reassessment is essential to evaluate treatment efficacy and adjust approach 2
• Most patients remain on the same medication dose throughout treatment, with only about 20% continuing treatment for ≥1 year 6
• Combination of non-pharmacological and pharmacological approaches may be more effective than either alone 2, 7
• Fibromyalgia commonly coexists with other conditions like back pain, hypertension, headache, depression, and sleep disorders that may require additional management 6

Treatment Pitfalls to Avoid

• Relying solely on pharmacological therapy without implementing exercise and behavioral approaches 1, 2
• Using strong opioids or corticosteroids, which lack evidence for benefit and carry significant risks 2, 5
• Failing to address sleep disturbances, which can exacerbate pain and fatigue 2, 8
• Not providing adequate patient education about the chronic nature of fibromyalgia 1, 2
• Focusing only on pain without addressing associated symptoms like fatigue, cognitive dysfunction, and mood disturbances 5, 8