What are the recommended management strategies for fibromyalgia?

Fibromyalgia Management

Start with Exercise as Primary Treatment

Begin immediately with aerobic and strengthening exercise as the foundation of fibromyalgia management—this has the strongest evidence (Level Ia, Grade A) and should be initiated before or alongside any pharmacological therapy. 1, 2

Exercise Protocol

• Initiate low-impact aerobic exercise (walking, swimming, cycling) at 20-30 minutes, 2-3 times weekly 2
• Gradually increase to 30-60 minutes, 5 days weekly based on tolerance 2
• Add progressive resistance training 2-3 times weekly 2
• Heated pool therapy or hydrotherapy provides additional benefit and may improve exercise tolerance 1, 2
• Titrate intensity gradually to avoid symptom flare-ups—this is a critical pitfall where aggressive progression causes treatment abandonment 1

All forms of exercise improve pain (effect size -0.72 to -0.96) and depression (effect size -0.35 to -1.22), with mind-body and strengthening exercises particularly effective for fatigue (effect size -0.77 to -1.00) and aerobic/strengthening exercises superior for sleep (effect size -0.74 to -1.33). 3

Add Behavioral Interventions

• Cognitive behavioral therapy (CBT) is recommended (Level Ia, Grade A) particularly for patients with depression, anxiety, or maladaptive coping strategies 1, 2
• Acupuncture reduces pain with Level Ia, Grade A evidence 2
• Meditative movement therapies including tai chi, yoga, or qigong are recommended with Level Ia, Grade A evidence 1, 2
• Mindfulness-based stress reduction programs are recommended with Level Ia, Grade A evidence 1, 2

CBT improves pain, sleep, and depression (effect size -0.35 to -0.55) but notably does not improve fatigue, which requires exercise-based interventions. 3

Pharmacological Therapy Algorithm

Add first-line medications only after initiating non-pharmacological therapies or when exercise alone provides insufficient relief. 1, 2 The European League Against Rheumatism has downgraded most pharmacological treatments to "weak for" recommendations while exercise remains "strong for." 4

First-Line Medication Selection

Choose based on predominant symptom profile:

• Amitriptyline 10-25 mg at bedtime for patients with prominent sleep disturbance and pain 2

  • Titrate by 10-25 mg weekly to 50-75 mg as tolerated (maximum 75 mg/day) 1, 2
  • Level Ia, Grade A evidence for pain reduction and improved function 1
  • Most beneficial for patients with sleep disturbances due to sedating properties 1

• Duloxetine 30 mg daily for 1 week, then 60 mg daily for patients with pain plus depression or anxiety 2

  • Level Ia, Grade A evidence for pain reduction and functional improvement 1
  • Target dose 60 mg/day 1

• Pregabalin 75 mg twice daily, titrate to 150 mg twice daily over 1 week for patients with predominant pain without mood symptoms 2

  • Recommended dose 300-450 mg/day for fibromyalgia 5
  • May increase to 225 mg twice daily (450 mg/day) if insufficient benefit at 300 mg/day 5
  • Do not exceed 450 mg/day—no evidence of additional benefit at 600 mg/day with increased adverse effects 5
  • Level Ia, Grade A evidence for pain reduction and sleep improvement 1
  • Requires dose adjustment in renal insufficiency 1

Alternative First-Line Options

• Milnacipran 100-200 mg/day in divided doses is effective for pain reduction and fatigue 1

  • Dose escalation starting at lower doses, titrating up over approximately 1 week 1
  • Level Ia, Grade A evidence 1
  • Dropout rates due to side effects approximately double compared to placebo 1

• Cyclobenzaprine can be considered for pain management with Level Ia, Grade A evidence 1

Second-Line Medication

• Tramadol for pain management (Level Ib, Grade A) when first-line medications are ineffective 1, 2
• Gabapentin is an alternative to pregabalin with similar mechanism of action, though not FDA-approved for fibromyalgia 1
  • Requires careful titration due to nonlinear pharmacokinetics (saturable absorption) 1
  • Start with low doses and gradually increase 1
  • Requires dosage adjustment in renal insufficiency 1

Critical Medications to Avoid

These represent common prescribing errors that waste time and expose patients to unnecessary risks:

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

Monitoring and Reassessment Protocol

• Evaluate treatment response every 4-8 weeks using pain scores (0-10 scale), functional status, and patient global impression of change 1, 2
• If insufficient response after 4-6 weeks of non-pharmacological therapy, add additional modalities (CBT, acupuncture, mindfulness) 1
• If partial pain relief with medication, consider adding another first-line medication from a different class 1
• If no or inadequate pain relief at target dosage after adequate trial, switch to alternative first-line medication 1

Setting Realistic Expectations

Most treatments show modest effect sizes—expect 30-50% pain reduction rather than complete resolution. 2 This is critical for patient education to prevent treatment abandonment when unrealistic expectations are not met. 1, 2

Multicomponent therapy (combining exercise, CBT, and medication) provides greater benefit than any single intervention, though the absolute benefit remains modest for many patients. 1, 2, 4 Meta-analysis demonstrates that nonpharmacological treatments are more efficacious in improving self-reported fibromyalgia symptoms than pharmacological treatment alone. 6

Long-Term Management

• Ongoing exercise maintenance is essential for sustained benefit 2
• Periodic reassessment of medication need as some patients may be able to reduce or discontinue pharmacological therapy with sustained non-pharmacological interventions 2
• Regular reassessment is essential to evaluate treatment efficacy and adjust the approach as needed 1