What are the recommended treatment options for fibromyalgia?

Treatment of Fibromyalgia

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 in fibromyalgia. 1, 2

Initial Non-Pharmacological Management (First-Line)

Exercise Program (Strongest Evidence)

• Start with low-impact aerobic exercise (walking, swimming, cycling) at 20-30 minutes, 2-3 times weekly, gradually increasing to 30-60 minutes, 5 days weekly 2
• Add progressive resistance training 2-3 times weekly once aerobic tolerance is established 2
• All forms of exercise improve pain (effect size -0.72 to -0.96) and depression (effect size -0.35 to -1.22) except flexibility exercise alone 3
• Mind-body exercises (tai chi, yoga, qigong) and strengthening exercises specifically improve fatigue (effect size -0.77 to -1.00) 3, 1
• Aerobic and strengthening exercises improve sleep (effect size -0.74 to -1.33) 3

Heated Pool Therapy/Hydrotherapy

• Heated pool treatment with or without exercise provides additional benefit and may improve exercise tolerance (Level IIa, Grade B) 1, 2

Cognitive Behavioral Therapy

• Prioritize CBT for patients with depression, anxiety, or maladaptive coping strategies, as it shows the strongest benefit in this subgroup (Level Ia, Grade A) 1, 2
• CBT improves pain, sleep, and depression (effect size -0.35 to -0.55) but does not significantly improve fatigue 3

Additional Supportive Therapies

• Acupuncture reduces pain (Level Ia, Grade A) 1, 2
• Mindfulness-based stress reduction programs are beneficial (Level Ia, Grade A) 1
• Meditative movement therapies including tai chi, yoga, or qigong are recommended (Level Ia, Grade A) 1, 2

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

First-Line Medications (All Level Ia, Grade A Evidence)

Amitriptyline 1, 2

• Start 10 mg at bedtime, increase by 10 mg weekly to target 25-50 mg nightly (maximum 75 mg) 1, 2
• Most beneficial for patients with prominent sleep disturbance and pain 2
• Monitor for anticholinergic effects (dry mouth, constipation, urinary retention) and morning sedation 2

Duloxetine 1, 2, 4

• Start 30 mg once daily for 1 week, then increase to 60 mg once daily 2, 4
• Optimal for patients with pain plus comorbid depression or anxiety 2
• No evidence that doses greater than 60 mg/day confer additional benefit 4
• FDA-approved for fibromyalgia 1

Pregabalin 1, 2

• Start 75 mg twice daily, titrate to 150 mg twice daily over 1 week based on tolerance (target 300-450 mg/day) 1, 2
• Best for patients with predominant pain without mood symptoms 2
• Reduces pain and improves sleep 2
• FDA-approved for fibromyalgia 1

Alternative First-Line Options

Milnacipran 1, 5

• Start with dose escalation over approximately 1 week, target maintenance 100-200 mg/day in divided doses 1, 5
• Effective for pain reduction and fatigue symptoms 1
• No evidence that 200 mg/day confers greater benefit than 100 mg/day 5
• FDA-approved for fibromyalgia 1

Cyclobenzaprine 1

• Can be considered for pain management (Level Ia, Grade A) 1

Second-Line Medication (When First-Line Options Ineffective)

Tramadol 1

• Recommended for pain management (Level Ib, Grade A) when other medications are ineffective 1

Critical Medications to Avoid

• Corticosteroids have no role in fibromyalgia treatment and should never be prescribed 1, 2
• Strong opioids (morphine, oxycodone, hydrocodone) are not recommended as 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

Treatment Algorithm

Step 1: Provide patient education about central sensitization and begin graduated exercise program immediately 2

Step 2: If insufficient response after 4-6 weeks of exercise, add one first-line medication based on symptom profile:

• Sleep disturbance predominant → Amitriptyline 2
• Depression/anxiety comorbid → Duloxetine 2
• Pain predominant without mood symptoms → Pregabalin 2

Step 3: If partial response at 4-8 weeks, consider adding CBT or other non-pharmacological therapies (acupuncture, hydrotherapy, mindfulness) 1, 2

Step 4: If inadequate response at target dosage after adequate trial, switch to alternative first-line medication from different class 1

Step 5: If still inadequate response, consider tramadol as second-line option 1

Monitoring and Reassessment

• Evaluate treatment response every 4-8 weeks using pain scores (0-10 scale), functional status, and patient global impression of change 2
• Most treatments show modest effect sizes; expect 30-50% pain reduction rather than complete resolution 2
• Multicomponent therapy (combining exercise, CBT, and medication) may provide greater benefit than any single intervention 6, 2
• Long-term management requires ongoing exercise maintenance and periodic reassessment of medication need 2

Common Pitfalls to Avoid

• Never rely solely on pharmacological therapy without implementing exercise and behavioral approaches 1
• Avoid starting multiple medications simultaneously; add one at a time to assess individual efficacy 2
• Do not prescribe corticosteroids or strong opioids under any circumstances 1, 2
• Recognize that fibromyalgia represents abnormal central pain processing (central sensitization) rather than peripheral tissue damage or inflammation 2
• When discontinuing duloxetine, use gradual dose reduction rather than abrupt cessation to minimize withdrawal symptoms (dizziness, headache, nausea, paresthesia) 4