What is the recommended workup and treatment for fibromyalgia?

Fibromyalgia Workup

Fibromyalgia is a clinical diagnosis that requires no laboratory testing or imaging—focus on identifying widespread pain for at least 3 months, assessing tender points, and excluding alternative diagnoses through targeted history and physical examination. 1, 2

Diagnostic Approach

Clinical Criteria

• Use the American College of Rheumatology criteria: widespread pain in all four quadrants of the body for at least 3 months, plus pain on palpation in at least 11 of 18 specific tender points 3, 4
• Alternative screening: The Fibromyalgia Rapid Screening Tool provides a quick method to identify patients who warrant full diagnostic evaluation 3
• Recognize the core symptom cluster: diffuse chronic pain, poor sleep quality, profound fatigue, cognitive dysfunction ("fibro fog"), and mood disturbances (anxiety/depression) 3, 5

Essential History Elements

• Pain characteristics: Ask specifically about widespread musculoskeletal pain affecting all body quadrants, not localized to joints 4, 5
• Associated symptoms: Document sleep disturbances, fatigue severity, cognitive difficulties, and mood changes 3, 6
• Comorbid conditions: Screen for irritable bowel syndrome, chronic fatigue syndrome, temporomandibular disorder, and psychiatric diagnoses—these frequently coexist as "central sensitivity syndromes" 5
• Triggering events: Inquire about preceding physical trauma, emotional stress, or infections, though many cases lack identifiable triggers 4

Physical Examination

• Tender point assessment: Apply approximately 4 kg of pressure (enough to blanch the examiner's thumbnail) to the 18 designated tender points; positive if 11 or more are painful 1, 4
• Exclude inflammatory arthritis: Look for joint swelling, warmth, or true synovitis—their presence suggests alternative diagnoses 1
• Neurologic examination: Perform to exclude radiculopathy, myelopathy, or other neurologic conditions mimicking fibromyalgia 3

Laboratory Testing (Minimal and Targeted)

• Complete blood count and erythrocyte sedimentation rate: Order only to exclude inflammatory conditions like rheumatoid arthritis or polymyalgia rheumatica 1, 3
• Thyroid-stimulating hormone: Check to rule out hypothyroidism, which can mimic fibromyalgia symptoms 3
• Vitamin D level: Consider testing, though supplementation remains controversial for fibromyalgia treatment 7
• Avoid extensive autoimmune panels: Do not routinely order ANA, rheumatoid factor, or other autoimmune markers unless specific clinical features suggest rheumatologic disease 1, 3

Critical pitfall: Fibromyalgia involves no organic tissue damage or inflammation—normal laboratory results support rather than exclude the diagnosis 4. Excessive testing delays diagnosis, increases patient anxiety, and wastes resources 3.

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Treatment Algorithm

First-Line: Non-Pharmacological Interventions (Start Here)

Begin all patients with patient education about central sensitization, followed immediately by a graduated exercise program—these have the strongest evidence and should never be omitted. 2, 6

Patient Education

• Explain central sensitization: Describe fibromyalgia as abnormal pain processing in the central nervous system, not tissue damage, to set realistic expectations and reduce catastrophizing 1, 2
• Emphasize chronicity: Frame fibromyalgia as a manageable chronic condition requiring ongoing self-management strategies 2

Exercise (Highest Evidence: Level Ia, Grade A)

• Start with low-intensity aerobic exercise: Begin with 10-15 minutes of walking, swimming, or cycling 2-3 times weekly 2, 6
• Gradually increase intensity: Add 5 minutes every 1-2 weeks, targeting 30-40 minutes of moderate-intensity aerobic exercise 5 days weekly 2
• Add strength training: Incorporate resistance exercises 2-3 times weekly once aerobic tolerance improves 2
• Use heated pool therapy: Water-based exercise provides additional benefit through warmth and buoyancy (Level IIa, Grade B) 2

Critical pitfall: Aggressive exercise initiation causes symptom flares and treatment abandonment—slow progression is essential 2.

Cognitive Behavioral Therapy

• Prioritize for patients with mood disorders: CBT shows strongest benefit in those with depression, anxiety, or maladaptive coping strategies (Level Ia, Grade A) 2, 6
• Combine with exercise: Multicomponent therapy (CBT + exercise) demonstrates superior outcomes compared to either alone 2

Additional Non-Pharmacological Options

• Acupuncture: Provides pain relief with Level Ia evidence 2, 7
• Mindfulness-based stress reduction: Helps manage symptoms and improves quality of life 2
• Meditative movement therapies: Yoga, tai chi, and qigong show benefit (Level Ia, Grade A) 2

Second-Line: Pharmacological Management (Add if Inadequate Response After 4-6 Weeks)

If non-pharmacological interventions provide insufficient relief after 4-6 weeks, add amitriptyline, duloxetine, or pregabalin as first-line medications—these have FDA approval or strongest guideline support. 2, 3

First-Line Medications

Amitriptyline (Strongest Evidence: Level Ia, Grade A)

• Dosing: Start 10 mg at bedtime, increase by 10 mg weekly to target 25-50 mg nightly (maximum 75 mg) 2, 8
• Benefits: Reduces pain, improves sleep due to sedating properties, and enhances function 2, 3
• Monitoring: Watch for anticholinergic effects (dry mouth, constipation, urinary retention) and morning sedation 2

Duloxetine (Level Ia, Grade A)

• Dosing: Start 30 mg once daily for 1 week, then increase to 60 mg once daily 8
• Benefits: Reduces pain, improves function, and treats comorbid depression 2, 3
• Maximum dose: 60 mg daily—higher doses provide no additional benefit but increase adverse effects 8
• FDA-approved for fibromyalgia 3, 7

Pregabalin (Level Ia, Grade A)

• Dosing: Start 75 mg twice daily (150 mg/day), increase to 150 mg twice daily (300 mg/day) within 1 week based on tolerance 9
• Target dose: 300-450 mg/day in divided doses 9
• Maximum dose: 450 mg/day—the 600 mg/day dose shows no additional benefit and worse tolerability 9
• Benefits: Reduces pain and improves sleep 2, 3
• FDA-approved for fibromyalgia 9, 3

Milnacipran (Level Ia, Grade A)

• Dosing: Titrate over 1 week to 100-200 mg/day in divided doses 2
• Benefits: Reduces pain and fatigue 2, 3
• FDA-approved for fibromyalgia 3, 7

Choose based on comorbidities: Use amitriptyline for prominent sleep disturbance, duloxetine for comorbid depression, pregabalin for anxiety or sleep issues 2, 3.

Second-Line Medications (If First-Line Fails or Partial Response)

Tramadol (Level Ib, Grade A)

• Use when first-line medications fail: Tramadol provides pain relief but reserve for inadequate response to other agents 1, 2
• Dosing: Start 50 mg once or twice daily, titrate to 50-100 mg every 4-6 hours as needed (maximum 400 mg/day) 1
• Caution: Monitor for opioid-related adverse effects and dependence risk 1

Cyclobenzaprine

• Consider for muscle-related pain: Shows benefit in some patients (Level Ia, Grade A) 2, 7
• Dosing: 5-10 mg at bedtime 7

Gabapentin (Off-Label Alternative to Pregabalin)

• Use if pregabalin unavailable or unaffordable: Similar mechanism of action 2
• Dosing: Start 300 mg at bedtime, titrate slowly to 900-1800 mg/day in divided doses 7
• Requires renal dose adjustment 2

Medications to Avoid

Never prescribe corticosteroids or strong opioids for fibromyalgia—they lack efficacy and cause significant harm. 1, 2

• Corticosteroids: Not recommended—no evidence of benefit 1, 2, 3
• Strong opioids: Not recommended—no demonstrated benefits and high risk of dependence 1, 2, 3
• NSAIDs: Limited evidence of efficacy as monotherapy 3, 7

Treatment Monitoring and Adjustment

• Reassess every 4-8 weeks: Evaluate pain scores, functional status, and patient global impression of change 2
• If partial response: Add a medication from a different class (e.g., combine amitriptyline with duloxetine or pregabalin) 2
• If no response: Switch to an alternative first-line medication rather than increasing dose beyond recommended maximum 2, 8
• Multicomponent therapy: Combining non-pharmacological and pharmacological approaches provides greater benefit than either alone 2, 6

Critical pitfall: Most treatments show modest effect sizes—set realistic expectations that fibromyalgia management aims for symptom reduction and functional improvement, not complete pain elimination 2, 6.