What are the management options for fibromyalgia?

Management of Fibromyalgia

Exercise is the only intervention with strong evidence for fibromyalgia and should be initiated immediately as first-line therapy, followed by cognitive behavioral therapy for patients with mood disorders, with pharmacological agents (amitriptyline, duloxetine, or pregabalin) reserved for those with inadequate response to non-pharmacological approaches. 1, 2

Initial Management: Non-Pharmacological Interventions (First-Line)

Exercise (Strongest Evidence)

• Start with low-intensity aerobic exercise (walking, swimming, or cycling) at 10-15 minutes, 2-3 times weekly, gradually increasing to 30-60 minutes, 5 days weekly. 2, 3
• Add progressive resistance training 2-3 times weekly once aerobic tolerance is established. 3
• Exercise is the only therapy with a "strong for" recommendation based on meta-analyses (Level Ia, Grade A evidence). 1, 2
• Heated pool therapy or hydrotherapy provides additional benefit and may improve exercise tolerance. 2, 3
• Common pitfall: Patients often start too aggressively and experience symptom flare-ups; emphasize gradual progression to avoid this. 2

Cognitive Behavioral Therapy

• Prioritize CBT specifically for patients with depression, anxiety, or maladaptive coping strategies (Level Ia, Grade A evidence). 2, 3
• CBT shows strongest benefit in those with mood disorders and unhelpful coping patterns. 1, 2

Additional Non-Pharmacological Options

• Acupuncture provides pain reduction (Level Ia, Grade A evidence). 2, 3
• Meditative movement therapies (tai chi, yoga, qigong) are beneficial. 2, 3
• Mindfulness-based stress reduction programs show efficacy. 2, 3

Reassessment Point (4-6 Weeks)

• Evaluate treatment response using pain scores (0-10 scale), functional status, and patient global impression of change. 2, 3
• If insufficient response after 4-6 weeks of non-pharmacological therapy, proceed to pharmacological management. 2, 4

Pharmacological Management (Second-Line)

First-Line Medications (Choose Based on Clinical Presentation)

For patients with prominent sleep disturbance and pain:

• Amitriptyline 10 mg at bedtime, increase by 10 mg weekly to target 25-50 mg nightly (maximum 75 mg/day) (Level Ia, Grade A). 2, 4, 3
• Monitor for anticholinergic effects (dry mouth, constipation, urinary retention) and morning sedation. 4

For patients with pain plus depression or anxiety:

• Duloxetine 30 mg once daily for 1 week, then increase to 60 mg once daily (Level Ia, Grade A). 2, 4, 3, 5
• FDA-approved for fibromyalgia at 60 mg/day; no additional benefit demonstrated at 120 mg/day, with higher adverse event rates. 5
• Addresses both pain and comorbid mood disorders simultaneously. 2, 5

For patients with predominant pain without mood symptoms:

• Pregabalin 75 mg twice daily, increase to 150 mg twice daily (300 mg/day total) within 1 week based on tolerance (Level Ia, Grade A). 2, 4, 3, 6
• FDA-approved dosing for fibromyalgia: 300-450 mg/day in divided doses. 6
• Patients not responding to 300 mg/day may increase to 225 mg twice daily (450 mg/day), though no evidence supports doses above 450 mg/day. 6
• Critical caveat: Requires dose adjustment in renal impairment; check creatinine clearance before prescribing. 6

Alternative First-Line Option

• Milnacipran 100-200 mg/day in divided doses (Level Ia, Grade A), with dose escalation starting at lower doses over approximately 1 week. 2

Second-Line Medication (If First-Line Ineffective)

• Tramadol for pain management (Level Ib, Grade A) when other medications are ineffective. 2, 3

Medications with Weak Evidence

• Cyclobenzaprine shows very small improvement in sleep but not pain (NNT 4.8); consider only if other options fail. 1
• Gabapentin is an alternative to pregabalin with similar mechanism, though not FDA-approved for fibromyalgia; requires careful titration due to nonlinear pharmacokinetics. 2

Critical Medications to Avoid

Never prescribe the following for fibromyalgia:

• Corticosteroids have no role in fibromyalgia treatment (fibromyalgia is not an inflammatory condition). 2, 4, 3
• Strong opioids (morphine, oxycodone, hydrocodone) lack demonstrated benefit and carry significant risks. 2, 4, 3
• NSAIDs (ibuprofen, naproxen) have limited to no benefit as monotherapy since fibromyalgia involves central sensitization, not peripheral inflammation. 3

Ongoing Management and Monitoring

Regular Reassessment

• Evaluate treatment response every 4-8 weeks using pain scores, functional status, and patient global impression of change. 2, 3
• Set realistic expectations: Most treatments show modest effect sizes; expect 30-50% pain reduction rather than complete resolution. 1, 3

Combination Therapy

• Multicomponent therapy (combining exercise, CBT, and medication) may provide greater benefit than any single intervention. 2, 3
• Continue exercise maintenance long-term; periodically reassess medication need. 3

Treatment Algorithm Summary

1. Immediate initiation: Patient education + graduated exercise program 2, 4
2. Week 4-6: Add CBT if mood disorders present; add other non-pharmacological therapies (acupuncture, hydrotherapy, mindfulness) 2, 4
3. Week 6-8: If inadequate response, add pharmacological therapy based on symptom profile (amitriptyline for sleep, duloxetine for mood, pregabalin for pure pain) 2, 4, 3
4. Week 12-16: If partial response, consider adding second medication from different class; if no response, switch to alternative first-line medication 2
5. Ongoing: Maintain exercise program indefinitely; reassess medication efficacy every 4-8 weeks 2, 3

Important Clinical Pitfalls

• Do not delay exercise initiation while waiting for medication effects; exercise has the strongest evidence and should begin immediately. 1, 2
• Do not rely solely on pharmacological therapy; medications have modest effect sizes and work best when combined with exercise and behavioral approaches. 1, 3
• Do not prescribe strong opioids or corticosteroids; these lack efficacy and cause harm in fibromyalgia. 2, 4, 3
• Do not start exercise too aggressively; gradual progression prevents symptom flare-ups and improves adherence. 2
• Do not expect complete pain resolution; fibromyalgia is a chronic condition requiring ongoing management with realistic treatment goals. 1, 3