What are the treatment options for fibromyalgia?

Treatment Options for Fibromyalgia

Start with Exercise as Primary Treatment

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

Exercise Protocol

• 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
• Add progressive resistance training 2-3 times weekly once aerobic exercise is tolerated. 1
• Heated pool therapy or hydrotherapy provides additional benefit and may improve exercise tolerance. 2, 1
• Exercise should be gradually increased based on tolerance to avoid symptom flare-ups. 2
• All forms of exercise improve pain and depression except flexibility exercise alone. 3
• Mind-body and strengthening exercises specifically improve fatigue, while aerobic and strengthening exercises improve sleep. 3

Add Psychological and Mind-Body Interventions

• Cognitive behavioral therapy (CBT) is recommended for patients with depression, anxiety, or maladaptive coping strategies, with Level Ia, Grade A evidence. 2, 1
• CBT improves pain, sleep, and depression but not fatigue. 3
• Meditative movement therapies including tai chi, yoga, or qigong are recommended with Level Ia, Grade A evidence. 2, 1
• Mindfulness-based stress reduction programs are recommended with Level Ia, Grade A evidence. 2, 1
• Acupuncture is recommended for pain reduction with Level Ia, Grade A evidence. 2, 1

Pharmacological Therapy: Add Only If Non-Pharmacological Approaches Are Insufficient

First-Line Medications (Choose Based on Symptom Profile)

For patients with prominent sleep disturbance and pain:

• Start amitriptyline 10-25 mg at bedtime, titrate by 10-25 mg weekly to 50-75 mg as tolerated (Level Ia, Grade A). 2, 1
• Amitriptyline is particularly beneficial for patients with sleep disturbances due to its sedating properties. 2

For patients with pain plus depression or anxiety:

• Start duloxetine 30 mg daily for 1 week, then increase to 60 mg daily (Level Ia, Grade A). 2, 1
• Duloxetine 60 mg/day is effective for pain reduction, functional improvement, and associated depression. 2
• There is no benefit of 120 mg compared to 60 mg, and higher dosages are associated with more adverse reactions. 4
• Milnacipran 100-200 mg/day in divided doses is an alternative SNRI with effectiveness for pain reduction and fatigue symptoms. 2

For patients with predominant pain without mood symptoms:

• Start pregabalin 75 mg twice daily, titrate to 150 mg twice daily over 1 week (Level Ia, Grade A). 2, 1
• Pregabalin 300-450 mg/day is FDA-approved for fibromyalgia and effective for pain reduction and sleep improvement. 2, 5
• There is no evidence of greater effect on pain scores of 600 mg daily dose than 450 mg daily dose, but there is evidence of dose-dependent adverse reactions. 5
• Some patients experience pain decrease as early as Week 1. 5

Second-Line Medications

• Tramadol is recommended for pain management (Level Ib, Grade A) when first-line medications are ineffective. 2
• Cyclobenzaprine can be considered for pain management (Level Ia, Grade A). 2
• Gabapentin is an alternative to pregabalin with similar mechanism of action, though not FDA-approved for fibromyalgia. 2
• Gabapentin requires careful titration due to nonlinear pharmacokinetics, starting with low doses and gradually increasing. 2

Critical Medications to Avoid

• Corticosteroids have no role in fibromyalgia treatment and are not recommended. 2, 1
• Strong opioids (morphine, oxycodone, hydrocodone) are not recommended as they lack demonstrated benefit and carry significant risks. 2, 1
• NSAIDs (ibuprofen, naproxen) have limited to no benefit as monotherapy since fibromyalgia is not an inflammatory condition. 1

Monitoring and Reassessment Strategy

• Evaluate treatment response every 4-8 weeks using pain scores (0-10 scale), functional status, and patient global impression of change. 2, 1
• If partial pain relief is achieved with medication, consider adding another first-line medication from a different class. 2
• If no or inadequate pain relief occurs at target dosage after an adequate trial, switch to an alternative first-line medication. 2
• Most treatments show modest effect sizes; expect 30-50% pain reduction rather than complete resolution. 1

Combination Therapy Approach

• Multicomponent therapy combining exercise, CBT, and medication may provide greater benefit than any single intervention. 2, 1
• Long-term management requires ongoing exercise maintenance and periodic reassessment of medication need. 1

Common Pitfalls to Avoid

• Do not rely solely on pharmacological therapy without implementing exercise and behavioral approaches. 2
• Do not fail to provide adequate patient education about the chronic nature of fibromyalgia and central sensitization as the underlying mechanism. 2, 1
• Do not expect complete pain resolution; set realistic expectations of 30-50% improvement. 1
• Do not continue ineffective medications without reassessment and adjustment. 2