What are the recommended treatments for fibromyalgia?

Recommended Treatments for 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

First-Line: Non-Pharmacological Treatments

• Aerobic and strengthening exercise has the strongest evidence (Level Ia, Grade A) and should be the primary non-pharmacological intervention for improving pain, function, and quality of life 1, 2
• Cognitive behavioral therapy (CBT) is particularly beneficial for patients with concurrent mood disorders and unhelpful coping strategies (Level Ia, Grade A) 1, 2
• Multicomponent therapies that combine different approaches show significant benefit for overall symptom management (Level Ia, Grade A) 1, 2
• Acupuncture and hydrotherapy/heated pool treatment provide relief for many patients (Level Ia, Grade A) 1, 2
• Meditative movement therapies (qigong, yoga, tai chi) and mindfulness-based stress reduction can help manage symptoms (Level Ia, Grade A) 2

Second-Line: Pharmacological Treatments

• Amitriptyline at low doses (10-75 mg/day) is recommended for pain reduction and improved function (Level Ia, Grade A) 2
• Duloxetine or milnacipran (SNRIs) are effective for pain reduction and functional improvement (Level Ia, Grade A) 2, 3, 4
  • Duloxetine: Start at 30 mg once daily for 1 week, then increase to 60 mg once daily 3
  • Milnacipran: Effective at 100-200 mg/day, with 100 mg/day providing similar benefits to 200 mg/day 4
• Pregabalin is effective for pain reduction and is FDA-approved for fibromyalgia (Level Ia, Grade A) 2, 5, 6
  • Start at 25-50 mg at night and gradually increase to 300-450 mg divided twice daily 6
• Cyclobenzaprine can be considered for pain management (Level Ia, Grade A) 2
• Tramadol is recommended for pain management (Level Ib, Grade A) when other medications are ineffective 1, 2

Treatment Algorithm

1. Initial approach: Begin with patient education about fibromyalgia and implement aerobic and strengthening exercise program, with a gradual increase in intensity based on tolerance 1, 2
2. If insufficient response after 4-6 weeks: Add other non-pharmacological therapies such as CBT, hydrotherapy, acupuncture, or mindfulness-based stress reduction 2
3. If still inadequate response: Add pharmacological therapy starting with amitriptyline, duloxetine, milnacipran, or pregabalin 2, 7
4. For partial response to medication: Consider adding another first-line medication from a different class 2
5. For inadequate response to medication: Switch to an alternative first-line medication 2
6. For refractory cases: Consider tramadol for pain management when other medications are ineffective 1, 2

Important Considerations and Pitfalls

• Avoid corticosteroids and strong opioids as they are not recommended for fibromyalgia treatment and have not demonstrated benefits 2, 7
• The effect size for most treatments is relatively modest, with most showing small to moderate benefits 2
• Regular reassessment is essential to evaluate treatment efficacy and adjust the approach as needed 2
• Pregabalin and gabapentin require dosage adjustment in patients with renal insufficiency 2, 6
• Duloxetine should be tapered gradually rather than abruptly discontinued to avoid withdrawal symptoms 3
• Combination of non-pharmacological and pharmacological approaches may be more effective than either alone 2, 8
• NSAIDs have not demonstrated benefits for fibromyalgia and have significant limitations 7

By following this evidence-based approach, clinicians can effectively manage fibromyalgia symptoms and improve patients' quality of life through a combination of non-pharmacological and pharmacological interventions.