What are the guidelines for managing fibromyalgia?

Fibromyalgia Management Guidelines

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 patients. 1, 2

Initial Approach: Non-Pharmacological Interventions (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 exercise is tolerated 2
• Heated pool therapy or hydrotherapy provides additional benefit and may improve exercise tolerance (Level IIa, Grade B) 1, 2
• Exercise should be individually tailored and gradually increased based on tolerance to avoid symptom flare-ups 1

Cognitive Behavioral Therapy

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

Additional Non-Pharmacological Options

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

Pharmacological Management (Second-Line)

Add pharmacological therapy only if non-pharmacological interventions provide insufficient relief after 4-6 weeks. 3

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

Amitriptyline

• Start at 10 mg at bedtime, increase by 10 mg weekly to target 25-50 mg nightly (maximum 75 mg/day) 1, 2
• Best for patients with prominent sleep disturbance and pain 2
• Monitor for anticholinergic effects (dry mouth, constipation, urinary retention) and morning sedation 3

Duloxetine

• Start at 30 mg once daily for 1 week, then increase to 60 mg once daily 1, 2
• Best for patients with pain plus depression or anxiety 2
• Reduces pain, improves function, and treats comorbid depression 3

Pregabalin

• Start at 75 mg twice daily (150 mg/day), increase to 150 mg twice daily (300 mg/day) within 1 week based on tolerance 2, 4
• Maximum effective dose is 450 mg/day (225 mg twice daily); doses above 450 mg/day are not recommended due to dose-dependent adverse reactions without additional benefit 4
• Best for patients with predominant pain without mood symptoms 2
• Reduces pain and improves sleep 3
• Requires dosage adjustment in renal insufficiency 1, 4

Milnacipran

• Recommended dose is 100-200 mg/day in divided doses, with dose escalation starting at lower doses and titrating up over approximately 1 week 1
• Effective for pain reduction and fatigue symptoms 1

Second-Line Medication

Tramadol

• Consider only when first-line medications are ineffective (Level Ib, Grade A) 1
• Use with caution due to opioid properties 1

Alternative Options

• Cyclobenzaprine can be considered for pain management (Level Ia, Grade A) 1
• Gabapentin is an alternative to pregabalin with similar mechanism of action, though not FDA-approved for fibromyalgia 1

Critical Medications to Avoid

Never prescribe corticosteroids or strong opioids (morphine, oxycodone, hydrocodone) for fibromyalgia - they lack demonstrated benefit and carry significant risks. 1, 2, 3

NSAIDs (ibuprofen, naproxen) have limited to no benefit as monotherapy since fibromyalgia is not an inflammatory condition. 2

Treatment Algorithm

1. Week 0: Provide patient education about central sensitization and initiate low-intensity aerobic exercise (10-15 minutes, 2-3 times weekly) 3

2. Weeks 1-4: Gradually increase exercise intensity and duration; add heated pool therapy if available 1, 2

3. Week 4-6: If insufficient response, add CBT (especially if mood disorders present) and consider acupuncture or meditative movement therapies 2, 3

4. Week 6-8: If still insufficient relief, add first-line medication:

   • Amitriptyline if sleep disturbance is prominent 2
   • Duloxetine if depression/anxiety is present 2
   • Pregabalin if pain is predominant without mood symptoms 2

5. Week 12: If partial pain relief achieved, consider adding another first-line medication from a different class 1

6. Week 12: If no or inadequate pain relief at target dosage, switch to an alternative first-line medication 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 1, 2
• Expect 30-50% pain reduction rather than complete resolution - most treatments show modest effect sizes 2
• Multicomponent therapy (combining exercise, CBT, and medication) may provide greater benefit than any single intervention 1, 2

Common Pitfalls to Avoid

• Do not rely solely on pharmacological therapy without implementing exercise and behavioral approaches 1
• Do not skip patient education about the chronic nature of fibromyalgia and central sensitization 2, 3
• Do not prescribe strong opioids or corticosteroids - they are ineffective and harmful 1, 2
• Do not use NSAIDs as monotherapy - fibromyalgia is not an inflammatory condition 2
• Do not advance exercise intensity too rapidly - this can cause symptom flare-ups and treatment abandonment 1