What are the diagnosis and treatment options for fibromyalgia?

Fibromyalgia Diagnosis and Treatment

Diagnosis

Fibromyalgia is diagnosed clinically using the American College of Rheumatology criteria: widespread pain for at least 3 months plus pain at 11 or more of 18 specific tender point sites, though newer criteria no longer require tender point examination. 1, 2, 3

Clinical Presentation

• Patients present with chronic widespread pain, fatigue, nonrestorative sleep, cognitive dysfunction (often called "fibro fog"), and mood disturbances 4, 5
• The condition represents abnormal central pain processing (central sensitization) rather than peripheral tissue damage 1, 5
• Comorbid conditions frequently include irritable bowel syndrome, chronic fatigue syndrome, temporomandibular disorder, depression, and anxiety 4, 5

Diagnostic Approach

• Use the Fibromyalgia Rapid Screening Tool for initial screening in patients with diffuse chronic pain 4
• Comprehensive assessment must evaluate pain intensity, functional limitations, sleep quality, fatigue severity, cognitive symptoms, and psychosocial factors including depression and anxiety 1, 6
• Laboratory testing and imaging are not required for diagnosis but may be needed to exclude alternative diagnoses such as inflammatory arthritis, hypothyroidism, or vitamin D deficiency 4, 7

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Treatment Algorithm

Begin immediately with aerobic and strengthening exercise as the primary intervention, which has the strongest evidence (Level Ia, Grade A) for improving pain, function, and quality of life. 1, 6

Phase 1: Non-Pharmacological First-Line (Weeks 1-6)

Start with exercise therapy:

• Initiate low-impact aerobic exercise (walking, swimming, cycling) at 20-30 minutes, 2-3 times weekly, gradually increasing to 30-60 minutes, 5 days weekly 1, 6
• Add progressive resistance training 2-3 times weekly 1, 6
• Heated pool therapy or hydrotherapy provides additional benefit and may improve exercise tolerance 1, 6

Provide patient education:

• Explain fibromyalgia as a chronic condition involving central nervous system pain amplification, not tissue damage 1, 5
• Set realistic expectations that treatment aims to improve function and quality of life, not cure the condition 1

Phase 2: Add Additional Non-Pharmacological Therapies (Weeks 6-12)

If insufficient response after 4-6 weeks of exercise, add:

• Cognitive behavioral therapy (CBT), particularly for patients with depression, anxiety, or maladaptive coping strategies 1, 6
• Acupuncture for pain reduction (Level Ia, Grade A evidence) 1, 6
• Meditative movement therapies including tai chi, yoga, or qigong 1, 6
• Mindfulness-based stress reduction programs 1, 6

Phase 3: Pharmacological Therapy (If Inadequate Response to Non-Pharmacological Approaches)

First-line pharmacological options (choose ONE initially based on predominant symptoms):

For patients with prominent sleep disturbance and pain:

• Amitriptyline 10-25 mg at bedtime, titrate by 10-25 mg weekly to 50-75 mg as tolerated (Level Ia, Grade A) 1, 6
• Common side effects: dry mouth, constipation, morning sedation 6
• Avoid in elderly patients with cardiac conduction abnormalities or urinary retention 6

For patients with pain plus depression or anxiety:

• Duloxetine 30 mg daily for 1 week, then increase to 60 mg daily (Level Ia, Grade A) 1, 6, 3
• FDA-approved for fibromyalgia at 60 mg daily; no additional benefit from 120 mg dose 3
• Alternative: Milnacipran 12.5 mg daily, titrate to 100-200 mg daily in divided doses 6

For patients with predominant pain without mood symptoms:

• Pregabalin 75 mg twice daily, titrate to 150 mg twice daily over 1 week (maximum 450 mg/day) (Level Ia, Grade A) 1, 6, 2
• FDA-approved for fibromyalgia at 300-450 mg/day; 600 mg/day shows no additional benefit but increased adverse effects 2
• Requires dose adjustment in renal insufficiency 6
• Common side effects: dizziness, somnolence, peripheral edema, weight gain 2

Phase 4: Combination or Alternative Therapy (Weeks 12+)

If partial response to first medication:

• Add a medication from a different class (e.g., combine amitriptyline with duloxetine or pregabalin) 6
• Continue non-pharmacological therapies throughout 1, 6

If no response after adequate trial (8-12 weeks at target dose):

• Switch to alternative first-line medication from different class 6

Second-line pharmacological option:

• Tramadol 50 mg 1-2 times daily, titrate to maximum 300-400 mg/day in divided doses for refractory pain (Level Ib, Grade A) 1, 6
• Use only when first-line medications ineffective 6
• Monitor for opioid-related adverse effects and dependence risk 6

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Critical Pitfalls to Avoid

Medications that should NOT be used:

• Corticosteroids have no role in fibromyalgia treatment 1, 6
• Strong opioids (morphine, oxycodone, hydrocodone) are not recommended as they lack demonstrated benefit and carry significant risks 1, 6, 4
• NSAIDs (ibuprofen, naproxen) have limited to no benefit as monotherapy since fibromyalgia is not an inflammatory condition 4, 7

Common treatment errors:

• Starting with pharmacological therapy before implementing exercise and education 1, 6
• Failing to set realistic expectations about treatment goals (improvement vs. cure) 1
• Ordering extensive laboratory testing or imaging without clinical indication 4, 7
• Prescribing opioids for long-term management 4, 7
• Not reassessing treatment efficacy every 4-8 weeks 6

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Monitoring and Reassessment

• Evaluate treatment response every 4-8 weeks using pain scores (0-10 scale), functional status, and patient global impression of change 1, 6
• Most treatments show modest effect sizes; expect 30-50% pain reduction rather than complete resolution 1, 4
• Multicomponent therapy (combining exercise, CBT, and medication) may provide greater benefit than any single intervention 1, 6
• Long-term management requires ongoing exercise maintenance and periodic reassessment of medication need 1, 6