What are the 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 patients. 1, 2

Initial Non-Pharmacological Management (First-Line)

Exercise Program - Start Immediately

• Initiate 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 exercise tolerance. 2
• Exercise should be individually tailored and gradually increased based on tolerance to avoid symptom flare-ups. 1
• Heated pool therapy or hydrotherapy provides additional benefit and may improve exercise tolerance (Level IIa, Grade B). 1, 2

Additional Non-Pharmacological Interventions

• Cognitive behavioral therapy (CBT) is recommended for patients with depression, anxiety, or maladaptive coping strategies (Level Ia, Grade A), particularly those with mood disorders. 1, 2
• Acupuncture provides pain reduction with Level Ia, Grade A evidence. 2
• Meditative movement therapies (tai chi, yoga, qigong) are beneficial for sleep disturbances and fatigue (Level Ia, Grade A). 1, 2
• Mindfulness-based stress reduction programs are recommended. 2

Pharmacological Management (Second-Line)

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

First-Line Medications - Choose Based on Symptom Profile

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, 3
• Monitor for anticholinergic effects (dry mouth, constipation, urinary retention) and morning sedation. 3

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
• The 120 mg dose showed no additional benefit over 60 mg but increased adverse reactions and discontinuations. 4
• Effective for both pain reduction and comorbid depression. 4

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, 3
• Maximum effective dose is 450 mg/day (150 mg three times daily); 600 mg/day showed no additional benefit but increased adverse reactions. 5
• Requires dosage adjustment in renal insufficiency. 1
• Some patients experience pain reduction as early as Week 1. 5

Alternative SNRI option:

• Milnacipran 100-200 mg/day in divided doses, with dose escalation over approximately 1 week to minimize side effects. 1

Second-Line Medication

• Tramadol for pain management (Level Ib, Grade A) when first-line medications are ineffective. 1

Treatment Algorithm

1. Week 0-1: Patient education about central sensitization and chronic nature of fibromyalgia + initiate low-intensity aerobic exercise (10-15 minutes, 2-3 times weekly). 2, 3

2. Weeks 2-6: Gradually increase exercise intensity and duration + add heated pool therapy if available + consider CBT for patients with mood disorders. 1, 2

3. Week 4-6 evaluation: If insufficient response (less than 30% pain reduction), add one first-line medication based on symptom profile. 2, 3

4. Week 8-12 evaluation: Assess treatment response using pain scores (0-10 scale), functional status, and patient global impression of change. 1, 2

   • If partial response: Consider adding another first-line medication from a different class. 1
   • If no response: Switch to alternative first-line medication. 1

5. Ongoing management: Continue exercise maintenance indefinitely and periodically reassess medication need every 4-8 weeks. 1, 2

Critical Medications to Avoid

• Corticosteroids have no role in fibromyalgia treatment and should never be prescribed. 1, 2, 3
• 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

Important Clinical Considerations

• 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. 1, 2, 6
• The degree of pain reduction with duloxetine may be greater in patients with comorbid major depressive disorder. 4
• Gabapentin is an alternative to pregabalin with similar mechanism of action, though not FDA-approved for fibromyalgia; requires careful titration due to nonlinear pharmacokinetics. 1
• Regular reassessment every 4-8 weeks is essential to evaluate treatment efficacy and adjust the approach. 1, 2