What are the treatment options for fibromyalgia?

Treatment Options for Fibromyalgia

First-Line Treatment: Non-Pharmacological Interventions

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

Exercise Protocol

• 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 after establishing aerobic tolerance 2
• Heated pool therapy or hydrotherapy provides additional benefit and may improve exercise tolerance 1, 2
• Exercise should be gradually increased based on tolerance to avoid symptom flare-ups 1

Additional Non-Pharmacological Therapies (Add if Insufficient Response After 4-6 Weeks)

• Cognitive behavioral therapy (CBT) is particularly beneficial for patients with depression, anxiety, or maladaptive coping strategies (Level Ia, Grade A) 1, 2
• Acupuncture is recommended for pain reduction with Level Ia, Grade A evidence 1, 2
• Meditative movement therapies including tai chi, yoga, or qigong are recommended (Level Ia, Grade A) 1, 2
• Mindfulness-based stress reduction programs are recommended (Level Ia, Grade A) 1, 2
• Multicomponent therapy combining exercise, CBT, and other modalities may provide greater benefit than any single intervention 1, 2

Second-Line Treatment: Pharmacological Interventions

Add pharmacological therapy only if non-pharmacological interventions provide insufficient relief after 4-6 weeks of consistent implementation. 1, 2

First-Line Medications (Choose Based on Predominant Symptoms)

For patients with prominent sleep disturbance and pain:

• Amitriptyline 10-25 mg at bedtime, titrate by 10-25 mg weekly to 50-75 mg as tolerated (Level Ia, Grade A) 1, 2
• Particularly beneficial due to sedating properties 1

For patients with pain plus depression or anxiety:

• Duloxetine 30 mg daily for 1 week, then increase to 60 mg daily (Level Ia, Grade A) 1, 2, 3
• FDA-approved for fibromyalgia with demonstrated efficacy in reducing pain and improving function 3
• No benefit demonstrated for 120 mg compared to 60 mg, and higher dosage associated with more adverse reactions 3

For patients with predominant pain without mood symptoms:

• Pregabalin 75 mg twice daily, titrate to 150 mg twice daily over 1 week (Level Ia, Grade A) 1, 2, 4
• FDA-approved for fibromyalgia 1, 4
• Doses of 300-450 mg/day are effective; no evidence of greater effect with 600 mg daily dose but more dose-dependent adverse reactions 4

Alternative First-Line Medications

• Milnacipran 100-200 mg/day in divided doses with dose escalation starting at lower doses over approximately 1 week (Level Ia, Grade A) 1
• Cyclobenzaprine can be considered for pain management (Level Ia, Grade A) 1

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

• Tramadol is recommended for pain management (Level Ib, Grade A) when other medications are ineffective 1, 2
• Gabapentin is an alternative to pregabalin with similar mechanism of action, though not FDA-approved for fibromyalgia 1

Critical Medications to Avoid

• Corticosteroids have no role in fibromyalgia treatment and are not recommended 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 Summary

1. Immediate initiation: Patient education + aerobic and strengthening exercise program 1, 2
2. Week 4-6 assessment: If insufficient response, add heated pool therapy, CBT, acupuncture, or meditative movement therapies 1, 2
3. Week 8-12 assessment: If still insufficient response, add first-line pharmacological therapy based on predominant symptoms 1, 2
4. Ongoing reassessment: Evaluate treatment response every 4-8 weeks using pain scores (0-10 scale), functional status, and patient global impression of change 1, 2

Important Clinical Considerations

• Most treatments show modest effect sizes; expect 30-50% pain reduction rather than complete resolution 2
• Some patients experience pain decrease as early as Week 1 with pharmacological therapy, which persists throughout treatment 4, 3, 4
• Multicomponent therapy (combining exercise, CBT, and medication) may provide greater benefit than any single intervention 1, 2
• Long-term management requires ongoing exercise maintenance and periodic reassessment of medication need 2
• Patient education about fibromyalgia as a chronic condition with central sensitization is crucial for setting realistic expectations 1, 2

Common Pitfalls to Avoid

• Relying solely on pharmacological therapy without implementing exercise and behavioral approaches 1
• Not providing adequate patient education about the chronic nature of fibromyalgia 1
• Starting with medications before establishing non-pharmacological interventions, which have the strongest evidence 1, 2
• Using corticosteroids or strong opioids, which are contraindicated 1, 2
• Expecting complete pain resolution rather than realistic 30-50% improvement 2